Oasis At Pearland
Inspection history, citations, penalties and survey trends for this long-term care facility in Pearland, Texas.
- Location
- 3400 E Walnut, Pearland, Texas 77581
- CMS Provider Number
- 675557
- Inspections on file
- 35
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Oasis At Pearland during CMS and state inspections, most recent first.
During a lunch meal service, the facility did not follow the planned menu, resulting in residents receiving meals without the required fried rice or a suitable substitute, and serving green beans instead of oriental vegetables. The menu was not posted, and there was no substitution list available. The Dietary Manager and kitchen staff confirmed that rice was not available and no alternative starch was provided, contrary to facility policy.
A resident and her representative were not provided with timely access to requested medical records despite multiple written requests. The facility required completion of forms and payment before releasing records, but did not follow up with the appointed representative to resolve the matter, resulting in the records not being provided as required.
Several resident rooms experienced brown water and low water pressure following plumbing repairs, with staff and maintenance failing to promptly identify or address the issue. Observations and interviews confirmed that water quality checks were not performed after pipe work, resulting in unsanitary conditions and inadequate water supply for residents.
A resident with paraplegia and multiple medical conditions did not receive scheduled showers or adequate grooming assistance as required by their care plan. Despite being fully dependent for ADLs and having no documented refusals, the resident received infrequent bed baths and lacked grooming support, as confirmed by both the resident's statements and staff interviews. Facility staff could not provide consistent documentation of hygiene care, and the facility's policy for supporting dependent residents with ADLs was not followed.
Two residents, one with significant cognitive and physical impairments and another with dementia and wandering behaviors, were involved in an incident where one resident instructed the other to engage in inappropriate sexual contact. The event occurred despite staff training and facility policies on abuse prevention, as the resident with wandering tendencies was able to interact unsupervised with the vulnerable resident. The incident was reported by the victim and confirmed through interviews and documentation, highlighting a failure in supervision and protection.
A resident with a healing tracheostomy was admitted without physician orders for site care. Facility records, including the care plan and MAR, lacked documentation of the tracheostomy status. Staff interviews revealed that the trach site was closed upon admission, and minor drainage was not reported to the physician. The facility's policy required documentation of site care, which was not adhered to.
A facility failed to maintain a safe, clean, and homelike environment due to a linen shortage affecting six residents. Observations revealed multiple rooms without sheets and supply carts lacking linen. Staff interviews indicated persistent linen shortages, with the Administrator citing supply issues from an out-of-state vendor. The Maintenance Director suggested CNAs might be hiding or discarding linen. A resident's representative reported stained linens, and the Laundry Aide confirmed the shortage, noting continuous washing couldn't meet demand. No linen policy was provided during the survey.
A resident with multiple medical conditions, including cerebral palsy and gastrostomy, was not provided with pleasure feeding as ordered by the physician. Despite a modified barium swallow study indicating the resident could eat by mouth, observations and staff interviews revealed that the resident was consistently fed via a feeding tube without a meal tray for oral feeding. The DON admitted the order was unclear and had not been clarified with the physician, and the facility's policy did not address dietary requirements.
A facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate care for three residents. Observations revealed that residents were not repositioned or changed in a timely manner, leading to soiled diapers and offensive odors. Interviews with staff highlighted the challenges of inadequate staffing, with CNAs responsible for a high number of residents and unable to complete all necessary care tasks.
The facility failed to provide palatable and safe-temperature food for residents in Dove Hall receiving room trays. Observations showed food trays in a warmer without doors, leading to cold meals. Residents reported ongoing issues with cold food, particularly those served last. A test tray evaluation confirmed food temperatures were below required levels, with the Dietary Manager acknowledging the absence of hot covers and unheated carts as contributing factors.
The facility failed to maintain food safety and sanitation standards, with unlabeled food, improper cooler temperatures, and unclean equipment observed. The dishwashing process was compromised due to malfunctioning equipment and inadequate sanitization. Staff training and hygienic practices were insufficient, with a staff member failing to change gloves or wash hands after handling trash.
The facility failed to provide adequate staffing and supplies, resulting in residents not receiving timely incontinent care and repositioning. Observations showed residents left in soiled diapers, and interviews revealed insufficient CNAs and a lack of linens and briefs. The Administrator and DON were unaware of the extent of these deficiencies, impacting resident dignity and care.
A resident with a stage 4 pressure ulcer did not receive proper wound care, as the sacral wound was found without a covering dressing, contrary to physician's orders. The Wound Care Nurse and Charge Nurse were unaware of the missing dressing, and there was no documentation of the wound's measurements since admission. The facility's policy on wound monitoring was not followed, leading to a deficiency in care.
The facility failed to provide sufficient nursing staff, resulting in missed medications and inadequate care for residents. Critical medications were not administered, and residents with incontinence were not changed or repositioned during the night shift. Staff were aware of the shortages but did not take appropriate action to address the issue.
The facility failed to provide pharmaceutical services, resulting in four residents not receiving their prescribed medications, including insulin, anticoagulants, and an IV antibiotic. Blood glucose levels were not checked, and sliding scale insulin was not administered as ordered. The DON and the physician were unaware of the missed medications until notified by the surveyor.
The facility failed to ensure that four residents were free from significant medication errors, including missed doses of Coumadin, insulin, and IV antibiotics. The deficiency was attributed to staffing issues, where two nurses did not redistribute care of the residents, resulting in incomplete medication administration. The DON and Administrator were not aware of the missed medications until informed by the surveyor.
The facility failed to conduct and document a comprehensive facility-wide assessment, missing critical components such as the resident profile and facility resources needed. This oversight was identified during a review and interview with the Corporate RN and the new Administrator, who acknowledged the mistake and began working on the assessment. The facility's policy mandates an annual assessment to ensure the capacity to meet resident needs during normal and emergency operations.
The facility failed to ensure foods were properly stored, labeled, and dated in the kitchen, placing residents at risk of food-borne illness. Observations revealed several food items in the refrigerator and condiment refrigerator were not labeled or dated. Interviews with kitchen staff and the Administrator confirmed inconsistencies in following proper food labeling practices, especially after the departure of the kitchen supervisor and Dietary Manager.
The facility failed to provide a private meeting space for the residents' monthly council meetings, which were held in the dining room. Despite attempts to ensure privacy, multiple staff members, visitors, and other residents were observed entering and exiting the dining room during the meetings. Residents expressed their desire for a private space to speak freely without fear of being overheard by staff. The Administrator suggested using the conference room adjacent to her office for future meetings.
A resident with dementia and anxiety disorder was administered Olanzapine without a signed informed consent. The facility's process for obtaining consent was not followed, and the medication was given daily over a seven-day period. Interviews with staff confirmed the oversight, and the facility's policy did not include information on informed consent for antipsychotic medications.
A resident was administered Olanzapine without an appropriate diagnosis or consent. The facility's DON and ADON confirmed the lack of a valid diagnosis and consent, and the MHNP acknowledged the medication was given for behaviors not supported by the resident's documented conditions.
A CNA failed to perform proper hand hygiene during incontinent care for a resident with dementia and mobility issues, leading to potential cross-contamination. The DON confirmed the lapse in infection control practices, despite existing facility policies.
A resident with a tracheostomy did not receive care consistent with professional standards, as a respiratory therapist failed to use a pulse oximeter, did not hyper-oxygenate the resident, and contaminated the sterile field. The therapist also used non-sterile gloves, increasing the risk of infection. The facility lacked adequate supervision and training for respiratory therapists.
Failure to Follow Menus and Provide Required Meal Components
Penalty
Summary
The facility failed to follow the posted lunch menu as required, resulting in residents receiving meals that did not match the planned menu. During observation of the lunch service, trays were found to include an egg roll, chicken nuggets, green beans, banana pudding, juice, and water, but lacked the required fried rice or any substitute starch. There was also no posted menu or substitution list available in the dining room. The Dietary Manager confirmed that the menu should have included fried rice and oriental vegetables, but these items were not served. The Dietary Manager was unaware of why the rice was not included and noted that the vegetables served were green beans instead of the specified oriental vegetables. Further investigation revealed that rice was not available in the dry storage room, and food invoices showed no documentation that rice had been ordered for several delivery dates. The staff member responsible for preparing the meal stated she did not prepare fried rice due to the lack of rice and did not use an alternative starch, as she was concerned it might be needed for another meal. She also did not contact the Dietary Manager for guidance on substitutions. The facility's policy requires menus to meet nutritional needs, be posted, and substitutions to be made with nutritionally equivalent items, but these procedures were not followed during the observed meal service.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident and her representative with timely access to her personal and medical records upon request. The resident, who was cognitively intact and her own responsible party, had multiple diagnoses including type 2 diabetes mellitus with foot ulcer, chronic kidney failure, essential hypertension, chronic pain, muscle weakness, and urinary tract infection. Despite several written requests for her medical records sent by her representative, the facility did not provide the requested records within the required timeframe. Interviews with the facility's medical records staff revealed that the process for releasing records required completion of specific forms, notarization as applicable, and payment of any associated fees before records would be released. The staff member acknowledged receiving documentation requesting the records but stated that no payment had been received from the resident's representative. Furthermore, after being told by the representative not to call his phone number and to communicate through his appointed representative, the staff did not reach out to the appointed representative to resolve the matter. The facility's administrator was unaware of any unaddressed requests for records and indicated that all such requests were processed by the medical records staff. The facility's policy required validation of the request, notification of costs, and receipt of payment before releasing records, with a stated timeline of two days after payment. However, in this case, the resident and her representative were not provided with the requested medical records as required by regulation.
Failure to Maintain Sanitary Water Quality and Adequate Water Pressure
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in several resident rooms. Observations revealed that multiple rooms had brown water coming from faucets and very low water pressure, with water barely trickling out. These issues were noted in at least four rooms, with brown water observed for several minutes in some cases and low water pressure in others. Staff interviews confirmed that brown water was present in several rooms, and some staff members reported waiting for the water to run clear before using it. The facility's maintenance assistant indicated that recent plumbing work, including pipe changes and water shut-offs, likely contributed to the presence of sediment and brown water, as well as clogged faucet filters causing low water pressure. The facility administrator acknowledged that staff had not reported the brown water issue prior to the surveyor's observations and admitted that water quality checks were not performed after the plumbing work was completed. The facility's maintenance policy requires maintaining the building in a safe and operable manner, including compliance with regulations and routine maintenance, but these procedures were not followed to ensure water quality and pressure were restored after plumbing repairs. As a result, residents were exposed to unsanitary water conditions and inadequate water supply in their rooms.
Failure to Provide Scheduled Showers and Hygiene Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining grooming and personal hygiene, for a resident who was completely dependent due to paraplegia and other significant medical conditions. The resident, who had normal cognition and was dependent for all mobility and self-care, did not receive scheduled showers three times a week as required by his care plan for multiple weeks. Documentation showed missed or insufficient bathing during several specified weeks, and there was no evidence of the resident refusing these services during the period in question. Medical records indicated that the resident had a history of complete paraplegia, type 2 diabetes, heart failure, a stage 4 sacral pressure ulcer, neurogenic bowel, and neuromuscular bladder dysfunction. The resident was bedbound, required an indwelling catheter, and was admitted with multiple pressure ulcers. Despite these needs, the resident reported only receiving bed baths at most once a week and denied ever refusing care or requesting it at times when staff could not accommodate. Observations noted poor grooming, including long yellow nails and an untrimmed beard, and the resident expressed a desire for grooming assistance that was not offered. Interviews with facility staff revealed inconsistencies in the provision and documentation of showers and bed baths. Staff cited the use of a Shower Tech and CNAs for bathing duties, but could not provide consistent or complete records of care provided. The ADON and DON acknowledged expectations for regular hygiene care but were unable to produce documentation supporting that the resident received the scheduled showers or baths. The facility's own policy required assistance with ADLs for residents unable to perform them independently, including hygiene and grooming, but this was not consistently implemented for the resident in question.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, neglect, and exploitation, specifically failing to ensure that one resident was free from sexual abuse by another resident. On the date of the incident, a resident with significant cognitive and physical impairments, including cerebral palsy, intellectual disabilities, and dependence on staff for most activities of daily living, was subjected to inappropriate sexual contact by another resident. The perpetrator, who had recently been admitted and was known to wander throughout the facility due to dementia and altered mental status, instructed the victim to touch his private parts and body. The incident was reported by the victim to the Activity Director, who then relayed the information to supervisory staff. The victim's care plan documented cognitive impairment and a need for staff assistance with most activities, while the perpetrator's care plan noted wandering behavior and risk of elopement but did not indicate any prior aggressive or sexual behaviors. The two residents were not roommates and lived on separate halls, but the perpetrator was observed pushing the victim's wheelchair and interacting with him in common areas. Staff interviews confirmed that the incident was disclosed by the victim and that the perpetrator initially denied, then later admitted to the inappropriate contact during the facility's investigation. There was no direct witness to the abuse, but the victim consistently described the incident to multiple staff and family members. Documentation and interviews revealed that the facility's staff had been trained on abuse prevention, reporting, and resident rights, and that the facility had policies prohibiting abuse and neglect. However, the incident occurred despite these measures, as the perpetrator was able to access and interact with the vulnerable resident without adequate supervision or intervention. The deficiency was identified as past noncompliance, with the incident placing all residents at risk of abuse and neglect that could result in emotional and mental trauma.
Failure to Document and Report Tracheostomy Site Care
Penalty
Summary
The facility failed to ensure that a resident was admitted with physician orders for immediate care, specifically regarding the care of a healing tracheostomy site. The resident, a male with anoxic brain damage and chronic respiratory failure with hypoxia, was admitted without documented physician orders for tracheostomy site care. The care plan, medication administration record (MAR), and minimum data set (MDS) did not reflect the resident's tracheostomy status or the need for site care. Additionally, nursing notes and skin assessments conducted during the resident's stay did not document any tracheostomy site care or mention the healing tracheostomy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's tracheostomy site. An LVN noted that the tracheostomy site was closed upon admission and questioned the need for dressing. Another LVN observed scant drainage from the site but did not report it to the physician, believing it was part of the healing process. The Director of Nursing (DON) stated that even minor drainage should have been reported to the physician to clarify the need for an order. The facility's policy on trach care required documentation of the procedure, site condition, and resident response, which was not followed in this case.
Linen Shortage and Environmental Deficiency
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six residents, as observed during a survey. Multiple rooms were found without sheets on the beds, and supply carts in various halls lacked sheets. Interviews with staff, including a CNA and a Restorative Aide, revealed that linen shortages were a persistent issue, with insufficient linen available to meet residents' needs. The CNA mentioned waiting for linen from the laundry, and the Restorative Aide noted that linen was rarely available when she started her shift. The Administrator acknowledged the linen shortage, attributing it to supply issues with a company in another state that had experienced a disaster. Despite placing orders for linen, towels, and other supplies, the facility had not received the April order, and the recent order had not been delivered. The Administrator admitted to asking staff to dispose of stained sheets prematurely, exacerbating the shortage. The Maintenance Director/Housekeeping and Laundry Supervisor suggested that CNAs might be hiding or discarding linen, and he confirmed that linen availability was an ongoing issue. Interviews with other staff and a resident's representative highlighted further concerns. The Regional Nurse mentioned plans to source supplies from a local vendor, while a resident's representative reported stained and inadequate linens, leading her to bring in personal supplies. The Laundry Aide confirmed the shortage, stating that linens were often stained and had holes, and that they struggled to keep up with demand despite continuous washing. The facility lacked a linen policy, and no policy was provided during the survey.
Failure to Provide Ordered Pleasure Feeding
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of quality, specifically regarding pleasure feeding as ordered by the physician. The resident, a male with multiple diagnoses including volvulus, cerebral palsy, and gastrostomy, was admitted and readmitted to the facility with orders for pleasure feeding of puree textures upon family request. Despite a modified barium swallow study indicating the resident could eat by mouth, observations and interviews revealed that the resident was not provided with a meal tray for pleasure feeding during the observed lunch meal. The resident was instead fed via a feeding tube, and there was no documentation in the nurse progress notes indicating that the resident was given a pleasure tray or had refused to eat. Interviews with facility staff, including CNAs and the Director of Nursing (DON), confirmed that the resident was consistently fed via a feeding tube and that no meal trays were provided for oral feeding. The DON acknowledged that the order for pleasure feeding was unclear and admitted to not contacting the physician for clarification. The facility's policy on oral medication administration did not address dietary requirements, contributing to the oversight. This lack of adherence to the physician's order for pleasure feeding could place residents at risk for weight loss and further decline in health status.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of residents, specifically impacting three residents who were reviewed for sufficient staffing. The facility's assessment tool indicated a staffing plan based on the needs of the resident population, which included residents with behavioral needs, those requiring injections, tracheostomy care, and ventilator or respirator support. However, observations and interviews revealed that the facility did not have enough staff to provide necessary care, such as repositioning and incontinent care, for residents who were dependent on assistance for activities of daily living. Resident #1, a male with multiple diagnoses including muscle wasting and intellectual disabilities, was observed on multiple occasions with a soiled diaper and an offensive odor in his room, indicating a lack of timely incontinent care. His care plan required regular checks for incontinence and prompt changes to prevent skin breakdown and maintain dignity. Similarly, Resident #2, who had aphasia and cognitive deficits, was also observed with an offensive odor in his room and was not repositioned or changed in a timely manner, despite being dependent on assistance for personal hygiene and toileting. Resident #9, a female with dementia and a history of falling, reported being wet and not having been changed since early morning. Observations confirmed her sheets were drenched with urine, and a CNA noted that she had not been changed on the previous shift. Interviews with staff, including CNAs and the Director of Nursing, highlighted the challenges of inadequate staffing, with CNAs responsible for a high number of residents and unable to complete all necessary care tasks. The facility's staffing policy stated that sufficient numbers of staff with the necessary skills and competencies should be provided, but the observations and interviews indicated that this was not being achieved.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at a safe and appetizing temperature for residents in Dove Hall who received room trays from the facility's kitchen. Observations revealed that food trays were placed in a warmer without doors, and the food was covered with saran wrap. Residents reported receiving cold food, particularly those served last, and expressed that the issue had been ongoing despite previous complaints. The Dietary Manager and Administrator were aware of the problem, but the issue persisted, affecting the quality of meals served to residents. During a test tray evaluation, the food temperatures were found to be below the required levels, with baked beans at 110°F, beef brisket at 97°F, cold potato salad at 67°F, cold pureed potato salad at 57.8°F, pureed beans at 92.6°F, and pureed meat at 95.3°F. The Dietary Manager acknowledged that the food temperatures were low due to the absence of hot covers and unheated carts. The facility's policy on food preparation and service emphasized compliance with safe food handling practices, which was not adhered to in this instance, leading to the deficiency.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed in the kitchen. Food items, such as liquid eggs, were not labeled or dated, and the cooler's thermometer indicated a temperature of 44 degrees, which is above the safe range. Additionally, the stove and fryer were not properly cleaned, with burnt food particles and black oil observed. In the dry storage room, non-food items like a coffee cup and a bottle of pink liquid soap were improperly stored, indicating a lack of adherence to safe food handling practices. The dishwashing process was compromised due to malfunctioning equipment and inadequate sanitization. The dish machine's temperature did not exceed 90 degrees, and the sanitizer was not properly dispensed, as evidenced by the litmus paper not changing color. The lid with the tubing did not fit the sanitizer bottle, preventing proper sanitization. Furthermore, there was no fan to facilitate air drying of dishes, and the dish machine's operational requirements were not met, with wash and rinse temperatures below the required 120 degrees F. Staff training and hygienic practices were also inadequate. A dietary aide reported insufficient cleaning materials and a lack of proper training. During an observation, a staff member failed to change gloves or wash hands after handling trash, which was only corrected after being pointed out. The facility's policies on food preparation, storage, and dishwashing were not followed, leading to potential risks of food contamination and foodborne illness for residents consuming meals prepared in the kitchen.
Inadequate Staffing and Supplies Lead to Resident Care Deficiencies
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the care of three residents. The Administrator and Director of Nursing (DON) did not ensure sufficient staffing levels to provide timely incontinent care and repositioning for residents. Observations revealed that residents were left in soiled diapers for extended periods, indicating a lack of adequate care. Interviews with staff highlighted that the facility was operating with fewer CNAs than needed, making it difficult to meet the residents' needs. Additionally, the facility faced issues with inadequate supplies, including linens, towels, briefs, and wipes. The Administrator admitted to problems with linen supply due to issues with the vendor and acknowledged that there was not enough linen available. This shortage led to residents using stained and inadequate bedding, further compromising their dignity and care. The facility's supply closet was found to be insufficiently stocked, with only a limited number of briefs and wipes available. Interviews with the Administrator and DON revealed a lack of awareness regarding the extent of the care deficiencies. The Administrator was unaware of the residents not receiving timely care, and the DON believed that the staffing levels were adequate despite evidence to the contrary. The facility's failure to provide necessary resources and supervision placed residents at risk of skin breakdown, infection, and loss of dignity.
Deficiency in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in treatment and services consistent with professional standards of practice. The resident, who was admitted with a stage 4 pressure ulcer on the sacral region and a deep tissue injury on the right heel, did not have the sacral wound properly dressed. During an observation, it was noted that the sacral wound was packed with gauze but lacked a covering dressing, which was confirmed by the Wound Care Nurse (WCN) and the Certified Nursing Assistant (CNA) present. The Charge Nurse was unaware of the missing dressing, and there was no documentation of the wound's measurements since the resident's admission. The facility's records revealed that the sacral wound was to be cleaned and covered daily, as per a physician's order, but this was not adhered to. The WCN acknowledged that the wound should have been covered to prevent contamination and infection. Additionally, the facility's policy on wound monitoring was not followed, as there were no recorded measurements of the sacral wound in the resident's electronic record. The Director of Nursing (DON) confirmed that the WCN was responsible for ensuring wound care was completed, and if absent, other designated nurses would take over. However, the lack of communication and documentation led to the deficiency in care for the resident's pressure ulcer.
Staffing Shortages Lead to Missed Medications and Inadequate Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of residents, resulting in missed medication administration, inadequate monitoring of vital signs, and insufficient ADL care. Specifically, residents did not receive their prescribed medications, including anticoagulants, insulin, and blood pressure medications, which were critical for managing their health conditions. For example, Resident #34 did not receive Eliquis, Toprol, or Trileptal, and her blood glucose levels were not monitored as ordered. Similarly, Resident #65 missed doses of IV antibiotics, Haldol, Levetiracetam, and Oxcarbazepine, and her blood glucose was not checked as required. The facility also failed to provide adequate care for residents with bowel and bladder incontinence during the night shift. Residents reported not being changed or repositioned, leading to prolonged exposure to wet and soiled linens. Resident #19 was found sitting on a soaking wet bed, and Resident #41 reported that no CNA was available during the night shift, resulting in him lying in urine-soaked bedding. Resident #50 and Resident #59 also reported not receiving timely assistance with incontinence care, leading to discomfort and potential health risks. Interviews with staff revealed that the facility was aware of the staffing shortages but failed to take appropriate action to address the issue. The DON and Administrator were informed of the staffing problems but did not ensure that the remaining staff redistributed care responsibilities or provided additional support. This lack of action resulted in residents missing critical medications and not receiving necessary care, placing them at risk for adverse health outcomes.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services, including dispensing and administering all drugs and biologicals, to meet the needs of four residents. This deficiency was observed when one of the three nurses assigned to the South Hall called off from her shift, and the remaining staff did not redistribute the assignments. As a result, several residents did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered. Additionally, residents did not receive their morning and/or afternoon medications as ordered by their physician, including critical medications such as insulin, anticoagulants, and an IV antibiotic. Resident #34, who had severe cognitive impairment and multiple diagnoses including type 2 diabetes mellitus and epilepsy, did not receive her prescribed medications, including Eliquis, Toprol, and Trileptal. Her blood glucose levels were not checked at the scheduled times, and no sliding scale insulin was administered. Similarly, Resident #65, who had moderately impaired cognition and multiple diagnoses including type 2 diabetes mellitus and schizophrenia, missed several doses of her medications, including an IV antibiotic, Haldol, Levetiracetam, and Oxcarbazepine. Her blood glucose levels were also not checked, and sliding scale insulin was not administered. Resident #87, who had severely impaired cognition and multiple diagnoses including type 2 diabetes mellitus and atrial fibrillation, did not receive her prescribed medications, including Apixaban, Amiodarone, and Metoprolol Tartrate. Her blood glucose levels were not checked, and sliding scale insulin was not administered. Resident #91, who had intact cognition and multiple diagnoses including diabetes mellitus and congestive heart failure, did not receive his prescribed medications, including Coumadin, Hydralazine HCl, and Carvedilol. His blood glucose levels were not checked, and sliding scale insulin was not administered. The DON and the physician were not aware of the missed medications until notified by the surveyor.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure that four residents were free from significant medication errors. Resident #91 did not receive Coumadin as ordered by the physician, placing him at risk for a blood clot. Additionally, Residents #34, #65, and #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered. Resident #34 also did not receive Metoprolol Tartrate as ordered, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. Resident #65 did not receive a dose of IV antibiotic for a sacral pressure ulcer infection, and Resident #87 did not receive Metoprolol Tartrate as ordered, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. Missed medications included insulin, anticoagulants, and one IV antibiotic. The DON was not aware of the residents missing their medications prior to surveyor notification, and the physician was not notified until after the surveyor notified the DON. Resident #34, who has severe cognitive impairment, did not receive several medications on the morning of 04/22/24, including Eliquis, Toprol, and Trileptal Oral suspension. Her blood glucose levels were not checked at noon or 6:00 p.m., and no sliding scale insulin was administered. Resident #65, who has moderately impaired cognition, did not receive several medications on 04/22/24, including IV Ertapenem Sodium Solution, Haldol, Levetiracetam solution, and Oxcarbazepine. Her blood glucose was not checked as ordered, and sliding-scale insulin was not given. Resident #87, who has severely impaired cognition, did not receive several medications on 04/22/24, including Apixaban, Amiodarone, and Metoprolol Tartrate. Her blood glucose was not checked as ordered, and sliding-scale insulin was not administered. Resident #91, who has intact cognition, did not receive Coumadin, Hydralazine HCl, or Carvedilol as ordered on 04/22/24. His blood glucose was not checked as ordered, and sliding-scale insulin was not given. The deficiency was attributed to staffing issues on the South Hall, where there were only two nurses instead of the scheduled three. The nurses did not redistribute care of the South 3 residents, resulting in incomplete medication administration. The DON was responsible for finding replacement staffing but did not take appropriate action when informed of the staffing shortage. The Administrator was not aware of the missed medications until informed by the surveyor. The Corporate RN and NP were also not informed of the missed medications until after the surveyor's notification. The facility's failure to ensure proper medication administration placed the residents at higher risk for hyperglycemia, blood clots, and sepsis.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The Facility Assessment Tool was incomplete, missing critical components such as the resident profile, services and care offered, and facility resources needed. This deficiency was identified during a record review and interview with the Corporate RN, who acknowledged that the tool presented was merely a guide and not the actual assessment. The Corporate RN had been communicating the need for a proper assessment since December 2023, emphasizing its importance for determining staffing needs. Further interviews revealed that the new Administrator was unaware that the document presented was not the actual facility assessment. Upon realizing the mistake, the Administrator began working on the assessment with department heads. The facility's policy, dated Qtr 3, 2018, mandates an annual assessment to ensure the facility's capacity to meet resident needs during normal and emergency operations. The policy outlines specific data points and resources that must be reviewed, including resident census data, physical characteristics of the facility, equipment and supplies, and personnel details. The failure to complete the facility assessment as required by the policy could affect the residents by not ensuring that the necessary resources are available to provide appropriate care. The assessment is crucial for aligning resident needs with available resources, planning for emergencies, and making informed decisions about staffing, training, and equipment. The absence of a completed assessment indicates a significant oversight in the facility's operational planning and preparedness.
Failure to Properly Store, Label, and Date Food Items
Penalty
Summary
The facility failed to ensure foods were properly stored, labeled, and dated in the kitchen, which could place residents at risk of food-borne illness. During an observation and interview with Cook A, it was found that several food items in the refrigerator were not labeled with a use-by date, including puree pumpkin pudding, salad mix, croissants, bagels, and pancakes. Additionally, the condiment refrigerator contained several items such as potato salad, ham, turkey, sliced cheese, shredded cheese, tomatoes, bell peppers, and jalapenos that were not labeled or dated. Cook A mentioned that the food should be labeled and dated with the open date and that the evening staff was responsible for cleaning and checking for expired items. However, this practice was not being followed consistently, especially after the kitchen supervisor left eight days prior to the observation. In an interview with Cook B, it was confirmed that the cooks were responsible for labeling the food and that opened food should be labeled and dated. The Administrator acknowledged that the Dietary Manager had left two weeks ago and that a new Dietary Manager was scheduled to start soon. The Administrator also mentioned that she was overseeing the kitchen in the interim and that whoever was putting away food after delivery was responsible for labeling it. The facility's Food Receiving and Storage policy and the Texas Food Code were reviewed, both of which require proper labeling and dating of stored food to ensure safety. The failure to adhere to these standards was evident in the observations made during the survey.
Lack of Private Meeting Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly council meetings, which were held in the dining room. Despite the Activities Director's attempt to post a sign and request staff to stay out, multiple staff members, visitors, and other residents were observed entering and exiting the dining room during the meetings. This lack of privacy was confirmed through interviews with residents who expressed their desire for a private space to speak freely without fear of being overheard by staff. The Activities Director acknowledged the issue but stated that no other rooms were available, as the only potential alternative was being used for dialysis storage. The Administrator was aware that the meetings were held in the dining room and had attended a previous meeting where a 'don't enter' sign was posted. However, the Administrator was informed of the surveyor's observations of staff and visitors entering the dining room during the meetings. The Administrator suggested that the conference room adjacent to her office could be used for future meetings, as it would provide the necessary privacy. Record reviews of the Resident Council Minutes from the past three months confirmed that the meetings were consistently held in the dining room, with varying numbers of residents in attendance. The facility's Resident Council policy supports residents' rights to organize and participate in council meetings, but the current practice did not align with the policy's intent to provide a private forum for residents to voice their concerns and suggestions for improvement.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment, specifically for one resident who was administered antipsychotic medication without a signed consent. Resident #58, a female with diagnoses including unspecified dementia and anxiety disorder, was given Olanzapine without the necessary informed consent. The comprehensive MDS assessment indicated that Resident #58 was unable to complete the BIMS, and the care plan noted the use of psychotropic medication with a focus on monitoring for adverse reactions and effectiveness. Despite this, the facility did not obtain a signed consent for the administration of Olanzapine, which was documented in the MAR as being administered daily over a seven-day period. Interviews with the DON and ADON revealed that the facility's process for obtaining informed consent for psychotropic medications was not followed. The DON stated that nurses should ensure appropriate diagnoses and consents are in place before administering such medications. The ADON, who was recently hired, confirmed that Resident #58 was receiving Olanzapine for behaviors related to dementia but acknowledged that no current consent for treatment was on file. The ADON mentioned working on a process to ensure all consents are signed prior to administering psychotropic medications. The MHNP confirmed that Olanzapine was prescribed for Resident #58 due to behaviors previously identified by the facility, despite dementia not being an appropriate diagnosis for antipsychotic medication. The MHNP was unaware that the facility lacked a signed informed consent and stated that such consent should be obtained before administering antipsychotic medications. The facility's policy on administering medications did not include information related to antipsychotic medication informed consent, further contributing to the deficiency.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that psychotropic medications were not given unless necessary to treat a specific condition as diagnosed and documented in the clinical record for one resident. Specifically, Resident #58 was administered Olanzapine, an antipsychotic medication, without an appropriate diagnosis or indication. The resident's diagnoses included unspecified dementia and anxiety disorder, but there was no documented diagnosis justifying the use of Olanzapine. The resident's care plan and physician's orders did not provide a valid reason for the medication, and the facility lacked a current consent for treatment with the antipsychotic medication. Observations revealed that Resident #58 was frequently found in bed with eyes closed, appearing to be sleeping, which could be indicative of the medication's side effects. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the facility did not have the appropriate diagnosis or consent for the use of Olanzapine. The DON acknowledged that dementia was not an appropriate diagnosis for an antipsychotic medication and highlighted the risks associated with unnecessary antipsychotic use, such as falls, weight loss, heart conditions, and decreased socialization. The Mental Health Nurse Practitioner (MHNP) confirmed that Olanzapine was prescribed for mood disorder with psychotic disorder, but Resident #58 did not have this diagnosis. The MHNP stated that the medication was given due to previously identified behaviors and agreed to follow up for a possible discontinuation. The facility's policy on administering antipsychotic medications did not include dementia as an appropriate diagnosis, and the facility failed to obtain informed consent prior to administering the medication.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident. Specifically, a CNA did not perform hand hygiene after removing soiled gloves and before touching clean items, which could lead to cross-contamination. The resident involved was an elderly female with dementia and other mobility issues, requiring extensive assistance with activities of daily living (ADLs) and was always incontinent of bladder and bowel. During an observation, the CNA was seen handling the resident's clean brief, shirt, pants, sheet, and blanket without changing gloves or performing hand hygiene after cleaning the resident's soiled areas. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA had not recently undergone competency checks for incontinent care and had only received infection control in-service training a few months prior. The DON, who had recently started working at the facility, acknowledged that the CNA should have performed hand hygiene to prevent infection risks. The facility's policies on hand hygiene and infection control were reviewed and found to be in place, but not adequately followed by the staff.
Deficient Tracheostomy Care and Suctioning Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as observed during a survey. The resident, who was admitted with acute respiratory failure and hypoxia, required tracheostomy care and suctioning. However, the respiratory therapist (RT A) did not follow professional standards of practice. Specifically, RT A did not use a pulse oximeter to monitor the resident's tolerance to the suctioning procedure and failed to hyper-oxygenate the resident before suctioning. Additionally, RT A contaminated the sterile field and did not wear sterile gloves when handling the inner cannula, which required surveyor intervention. During the procedure, RT A demonstrated a lack of understanding of sterile techniques. She double-gloved with gloves from a box by the door, incorrectly assuming they were sterile. RT A contaminated the sterile field by placing a non-sterile box on it and insisted that the gloves she used were sterile, despite being informed otherwise by the surveyor and another respiratory therapist (RT B). RT A's actions, including touching the tubing part of the new inner cannula with non-sterile gloves, increased the risk of infection for the resident. The facility lacked adequate supervision and training for respiratory therapists, as there was no RT Supervisor at the time of the incident. The Director of Nursing (DON) had recently left, and a new DON was yet to start. The Corporate RN acknowledged the deficiency in technique and planned to provide education to RT A. The facility's competency checklists and policies outlined the correct procedures for tracheostomy care, but these were not adhered to by RT A during the observed incident.
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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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