Onion Creek Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 1700 Onion Creek Pkwy, Austin, Texas 78748
- CMS Provider Number
- 676271
- Inspections on file
- 36
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Onion Creek Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple chronic conditions had numerous medications, including psychotropic, cardiac, diuretic, diabetic, and antibiotic therapies, discontinued after the MD assessed acute delirium and chose to minimize medications. MAR review confirmed that drugs such as alprazolam, divalproex sodium, mirtazapine, furosemide, eplerenone, glipizide, potassium chloride, and amoxicillin-clavulanate were stopped. The resident’s MPOA was not informed at the time of these significant treatment changes and only became aware after specifically questioning staff about a missing medication. Interviews with LVNs, the DON, the ADM, and the MD showed that facility practice and policy required nursing staff to notify residents or their representatives of medication changes and changes in condition, but this notification did not occur in this case.
A resident with dementia and behavioral disturbances was discharged from the hospital with an order for Depakote 250 mg BID, but the facility continued to administer the medication only once daily, resulting in six missed doses. Review of records and staff interviews confirmed that the hospital's discharge order was not transcribed or implemented, and there was no documentation of any order to discontinue or change the prescribed regimen.
A resident with severe cognitive impairment and multiple chronic conditions repeatedly refused medication and personal care, but these refusals were not addressed in the care plan. Despite documentation of the refusals by nursing staff and awareness among some team members, the care plan lacked any focus, goals, or interventions for these issues, contrary to facility policy and staff expectations.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely assistance in obtaining an eye exam or having her glasses repaired or replaced. Despite repeated requests from the family and documentation in the care plan, staff turnover and procedural delays resulted in the resident remaining without corrective lenses or vision services for an extended period.
A resident with multiple comorbidities was admitted with a skin alteration on the thoracic spine, but staff failed to initiate wound care interventions or treatment orders as required. The wound was not properly monitored or reassessed, leading to its progression to an unstageable pressure ulcer. Staff interviews and record reviews confirmed that admission protocols for skin assessment and intervention were not followed, resulting in a deficiency and Immediate Jeopardy finding.
A resident with a history of cognitive impairments and high elopement risk left a facility unsupervised and was found miles away. Despite being identified as a high-risk for elopement, the resident's care plan lacked focus on wandering, and staff were unaware of her departure. The facility's policy requiring staff authorization for residents leaving was not followed.
A resident with moderate cognitive impairment and a high risk for elopement left the facility without staff awareness. Despite signing out, staff were unaware of her departure until notified by another facility. The incident was not reported to the State Agency within the required timeframe, as the facility did not consider it an elopement due to the resident signing out. Staff expressed concerns about the resident's cognitive ability to make safe decisions.
A facility failed to implement hospital orders for a resident's diabetes management, resulting in delayed blood glucose monitoring and insulin administration. The resident experienced elevated blood sugar levels and expressed concerns about his care. Staff interviews revealed communication lapses, with the LVN unsure about insulin administration and the NP not informed of elevated levels. The DON acknowledged the oversight, noting that hospital orders should have been followed after review.
Two residents experienced significant delays in receiving their scheduled medications, ranging from 2.5 to 6 hours late, affecting their management of pain, anxiety, and respiratory conditions. The facility's liberal approach to medication administration contributed to these delays, as confirmed by staff interviews and medication records.
Two residents experienced significant medication errors due to delayed administration of their prescribed medications, with delays ranging from 2.5 to 6 hours. One resident reported heightened pain and anxiety symptoms due to the delays, while another experienced late administration of pain and respiratory support medications. Staff interviews revealed that the facility did not adhere to the standard medication administration timeframe, contributing to the deficiencies.
The facility's kitchen failed to meet food safety standards, with issues such as unlabeled and undated food items, inadequate dish sanitization, and improper storage of employee food. The dish machine's sanitizer concentration was below the required level, yet it continued to be used. The Dietary Supervisor and RDN identified these issues, but consistent monitoring and training were lacking.
The facility failed to ensure resident privacy as staff members, including an MDS, LVN, and CNAs, entered residents' rooms without knocking or announcing themselves. Despite being trained on resident rights and privacy, staff cited reasons such as forgetfulness and assumptions about residents' needs for not adhering to the policy. The facility's policy mandates knocking before entering to maintain a homelike environment.
The facility failed to provide adequate personal hygiene care for several residents, including trimming fingernails and toenails and shaving facial hair. A resident with minimally impaired cognition requested nail trimming, but it was not done. Another resident with severely impaired cognition had dirty and untrimmed nails, and a third resident had long, thick toenails that were not addressed. Additionally, a resident with facial hair was not shaved, despite family comments. Staff interviews revealed inconsistencies in care provision and a lack of documentation for care refusals.
The facility failed to ensure accurate MDS assessments for two residents, leading to discrepancies in their discharge records. One resident was incorrectly documented as discharged to a hospital when she went home AMA, while another was recorded as discharged home when he was actually transferred to a hospital. These errors were confirmed through record reviews and interviews with staff and family members. The MDS coordinator acknowledged the inaccuracies and began correcting them.
A resident with dementia and depression was not provided with regular, individualized activities, leading to a deficiency in meeting their well-being needs. Despite having a care plan, the resident's participation in activities was minimal, and there was a lack of documentation regarding encouragement or refusals. Interviews revealed the resident enjoyed physical activities, but staff reported difficulties in motivating them. The facility's policies emphasized providing activities based on preferences, but this was not consistently followed.
A resident with multiple health conditions, including heart failure and high blood pressure, did not receive the prescribed no salt added diet due to communication lapses in the facility. Observations showed meals with salt packets, and staff interviews revealed a lack of awareness about the resident's dietary needs. The dietary slip failed to mention the no salt added requirement, leading to the resident receiving an incorrect diet.
Failure to Notify Resident Representative of Significant Medication Discontinuations
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident’s representative when there was a significant alteration in treatment, specifically the discontinuation of multiple medications. An elderly male resident with severe cognitive impairment, metabolic encephalopathy, type 2 diabetes mellitus, altered mental status, unspecified dementia, and acute and chronic respiratory failure with hypoxia was admitted with multiple active care plans addressing cardiovascular status, renal status, pneumonia, diabetes, fluid balance, and antidepressant use. His admission MDS showed a BIMS score of 3, indicating severe cognitive impairment, and his MPOA identified a family member as the resident’s representative. On a documented physician visit, the MD’s initial H&P noted that the resident was a poor historian, alert and oriented x0, not eating or drinking, and refusing medications. The MD assessed presumed chronic diagnoses with acute delirium of unknown etiology and determined that the delirium could be related to medications, decreased oral intake, or dehydration. As part of the plan, the MD decided to minimize medications and discontinue several drugs, including Xanax (alprazolam), Depakote (divalproex sodium), mirtazapine, Lasix (furosemide), and potassium chloride. Review of the MAR confirmed that, around this time, orders for amoxicillin-potassium clavulanate, alprazolam, divalproex sodium, mirtazapine, furosemide, eplerenone, glipizide, and potassium chloride were discontinued. Interviews and record review showed that the resident’s family member, who was the MPOA, was not notified when these medications were discontinued. The family member reported not being informed of the medication changes and only learned that the resident was no longer receiving antidepressant or mood stabilizer medications after specifically asking about alprazolam several days later. Nursing staff and leadership (LVNs, DON, and ADM) stated that it was the nurse’s responsibility to notify the resident or POA of medication changes and that family should be notified of any medication changes, change in condition, or refusals. The MD stated he did not personally contact the POA or family unless requested and relied on nursing staff to notify them of changes. Facility in-service records and the written policy on change in condition indicated that residents or their representatives were to be notified of changes in condition and in medical or nursing care, but this did not occur for this resident when the medications were significantly altered.
Failure to Administer Medication as Ordered Following Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not following the physician's discharge orders after the resident returned from the hospital. The resident, who had a history of dementia with mood disturbances and behavioral issues, was discharged from the hospital with an order for Divalproex Sodium (Depakote) 250 mg to be administered twice daily (BID). However, upon readmission, the facility continued to administer the medication only once daily, as per a previous order, and did not implement the new BID order from the hospital. As a result, the resident missed six doses of the prescribed medication. Review of the resident's medical records and interviews with facility staff revealed that the hospital discharge order for Depakote 250 mg BID was not transcribed into the resident's clinical records or the Medication Administration Record (MAR). The nurse practitioner (NP) and other nursing staff confirmed that there was no documentation of a new order to discontinue the BID dosing or to revert to once-daily dosing. The facility's Director of Nursing (DON) and Assistant Director of Nursing (ADON) both acknowledged that the process for verifying and transcribing new orders upon readmission was not properly followed in this case. The ADON, who was responsible for auditing new admission and readmission medications, did not identify the error until it was brought to her attention during the survey. The resident's care plan and progress notes indicated ongoing behavioral disturbances and a need for mood stabilization, which were to be managed with antiepileptic medication as ordered. Despite the hospital's clear instructions to increase the Depakote dosage to BID, the facility failed to update the medication orders accordingly. There was no evidence in the clinical records of any order to discontinue or modify the hospital's discharge instructions, nor was there documentation explaining the deviation from the prescribed regimen.
Failure to Care Plan Resident's Refusal of Care and Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a documented history of refusing care and medication. Despite multiple nurse progress notes and eMAR entries indicating repeated refusals of both medication and personal care such as showers and bed baths over several months, there was no corresponding focus, goals, or interventions in the resident's care plan addressing these refusals. The care plan did not reflect the resident's ongoing pattern of care and medication refusal, which was a significant omission given the resident's severe cognitive impairment and complex medical diagnoses, including acute on chronic heart failure, vascular dementia, and cognitive communication deficit. Interviews with facility staff, including nurses, the MDS Coordinator, the Wound Care Nurse, the Administrator, and the DON, revealed a lack of communication and follow-through regarding the resident's refusals. While some staff were aware of the refusals and discussed them in clinical meetings, others, including the MDS Coordinator and DON, were not aware or did not recall these issues being brought up. Staff consistently stated that refusals of care and medication should be included in the care plan to ensure all team members are informed and appropriate interventions can be implemented. The facility's own policy required the interdisciplinary team to develop a comprehensive, person-centered care plan with measurable objectives and time frames to address all identified needs, including those related to medical, nursing, mental, and psychosocial care. However, the lack of documentation and care planning for the resident's refusals meant that staff did not have clear guidance or interventions to address these behaviors, as required by policy and best practice.
Failure to Assist Resident in Accessing Vision Services
Penalty
Summary
The facility failed to ensure that a resident received proper treatment to maintain vision abilities by not assisting in making necessary appointments for vision services. The resident, who had severe cognitive impairment and multiple diagnoses including vascular dementia and heart failure, was identified as being at risk for impaired visual function. The care plan included interventions such as arranging consultations with an eye care practitioner and reminding the resident to wear glasses. Despite these interventions, the resident did not have corrective lenses and did not receive timely assistance in obtaining an eye exam or having her glasses repaired or replaced. The resident's family began requesting assistance with the resident's glasses in early March, reporting that the glasses were loose and needed adjustment. Over the following months, the family repeatedly followed up with various facility staff regarding the status of the glasses and the need for an eye exam. The situation was complicated by staff turnover, including the departure of the staff member initially handling the request and the absence of a social worker for a period of time. Communication between the family and facility staff documented ongoing concerns about the resident's missing or broken glasses and the lack of an optometrist appointment. Facility staff acknowledged that the optometry provider required a minimum number of residents to schedule a visit, which further delayed the resident's access to vision services. The administrator and social worker confirmed that the resident's vision needs were not addressed due to staff changes and procedural delays. The resident remained without corrective lenses or an eye exam for several months, despite ongoing requests and documented needs.
Failure to Provide Timely Pressure Ulcer Care on Admission
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate pressure ulcer care and prevent the development of a new unstageable pressure ulcer for one resident at risk. Upon admission, the resident, an 89-year-old female with multiple comorbidities including pulmonary hypertension, chronic kidney disease, venous insufficiency, diabetes, and a history of myocardial infarction, was noted to have a skin alteration described as an abrasion or erythema on the thoracic spine. The initial assessment documented the presence of a wound, but no specific wound care interventions or treatment orders were initiated at that time. The resident's Braden score indicated a high risk for pressure sore development, and the care plan identified the potential for pressure ulcer development, but interventions were not implemented as required. Between the resident's admission and several days afterward, there was a lack of wound care treatment and preventive interventions. The wound was not properly monitored or reassessed, and no weekly skin/pressure ulcer assessment was documented until several days after admission. The wound subsequently progressed to an unstageable pressure ulcer, as confirmed by a wound care physician who performed debridement and described the wound as having slough and devitalized tissue. The physician and wound care nurse both indicated that the wound was not properly identified or managed upon admission, and the charge nurse responsible for the admission acknowledged an oversight in not initiating orders or monitoring the wound, citing insufficient education on admission expectations for skin concerns. Interviews with facility staff, including the DON and wound care physician, confirmed that the wound was mischaracterized at admission and that the required steps for assessment, documentation, and intervention were not followed. The facility's policies required a thorough skin check and immediate initiation of a wound flow sheet and treatment orders when a wound is identified, but these procedures were not adhered to. This failure placed the resident at risk for the development and worsening of a pressure ulcer, resulting in the identification of an Immediate Jeopardy situation by surveyors.
Removal Plan
- One on one in service with LVN Charge Nurse to review admission Skin Assessment/ Documentation Treatments and Notification. Overview of Resident #1 and education on expectations of interventions, notification, and documentation. LVNs knowledge and effectiveness of training by conducting quiz, chart audit and feedback given with results of audit, will continue training. LVN received counseling for insufficient assessment and documentation.
- Resident #1's head-to-toe skin assessment completed. Initiated medication review by Medical Provider, Wound Care Provider review of treatment orders for appropriateness. Social Service Assessment conducted to ensure psychosocial well-being. No mental anguish or psychological distress related to delay in treatment, notification of findings communicated to medical provider and Resident #1.
- In service provided to Administrator and DON by Clinical Resource on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions. In serviced on following up on new admission with chart audits and continue education and counseling as needed by Clinical Resource.
- 100% Charge Nurse In-Service for New Admission Skin Assessment/ Documentation Treatments and Notification. PRN nurses in serviced. We do not utilize agency staff. New staff will be in serviced upon hire. Nurses will not work floor until in serviced.
- Nurse Management in service for New Admission Skin Assessment/ Documentation Treatments and Notification and expectation to notify Medical Provider, Responsible Party and Treatment Nurse and Treatment nurse or designee to see all new admissions.
- Admissions, MDS, DOR, ADOR, Treatment Nurse, ADON informed of IJ, and template reviewed.
- Medical Director notified of IJ. Medical Director involved in development of plan and in agreement.
- An Ad hoc QA meeting will be completed. Attendees will include ED, DON, ADON, Clinical Resource, and Medical Director. Meeting will include the Plan of Removal and interventions.
- Audit on current residents with pressure ulcers.
- Audit on new admissions without Treatment Nurse Assessment. New admission Treatment Nurse Assessments are in place, Treatment in place when appropriate.
- Skin sweep on with residents with wounds and new admissions. Resulted in no new finding.
- RCA/QIT with IDT and Medical Director. IDT meet to discuss initial admission skin assessments that identify skin issues without treatment orders being placed initially by charge nurse and then a delay in treatment. This was often found on Friday admissions, where the treatment nurse did not see patients until the following week. All nurses being in-serviced prior to working their next shift on Admission skin assessment process, implementing orders and interventions and documentation. Treatment nurse was only assessing patient's that it was communicated had wounds. Treatment nurse or designee is to complete a skin assessment on all admissions on next working day to ensure accurate assessment and treatments are appropriate.
- Treatment Nurse, Admissions Nurse and MDS Resource to conduct in service to nurses trained on New Admission Skin Assessment/ Documentation Treatments and Notification and expectation.
- DON or designee to verify nurse knowledge on New Admission Skin Assessment/ Documentation Treatments and Notification by quizzing 5 nurses weekly and ongoing for nurse new hires
- Summary of IJ and corrective action to be reviewed by QAPI Committee monthly or until substantial compliance established.
- Care Plan audit for all residents with pressure/skin alterations. Care Plans update for appropriate interventions.
- Audit new Admissions for initial skin assessment and treatment nurse assessment, ensuring interventions and orders in place.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was identified as having a high risk for elopement. The resident, who had a history of psychotic disorder with delusions, generalized anxiety disorder, dementia, and unsteadiness on feet, left the facility without staff awareness. The resident was found approximately 4.2 miles away at a store off a major highway, after being contacted by an outside party. This incident occurred despite the resident's care plan indicating a need for supervision and assistance with decision-making. The resident's quarterly Elopement/Wandering Evaluation had previously indicated a high risk for elopement, yet there was no focus area related to wandering or elopement in the care plan. Staff interviews revealed that the resident had a history of attempting to leave the facility and required frequent redirection. On the day of the incident, the resident signed out at the front desk, but staff were unaware of her departure until notified by an external party. The facility's policy required staff to be informed and to authorize any resident leaving the premises, which was not adhered to in this case. Interviews with staff and family members highlighted a lack of communication and understanding of the resident's cognitive abilities and the facility's elopement policy. The resident's family member expressed concern over the resident's ability to leave the facility unsupervised, given her cognitive impairments. The facility's Director of Nursing and Administrator initially did not consider the incident an elopement, as the resident had signed out, but staff and family members disagreed, citing the resident's cognitive limitations and the potential for harm.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an incident involving a resident who left the facility without staff awareness, which was not reported to the State Agency within the required timeframe. The resident, a female with a history of psychotic disorder, generalized anxiety disorder, dementia, and unsteadiness, was identified as having a moderate cognitive impairment with a BIMS score of 10. Despite being at high risk for elopement, as indicated by her quarterly Elopement/Wandering Evaluation, the resident managed to leave the facility and was later found at a nearby store. On the day of the incident, the resident signed herself out at the front desk, but staff were unaware of her departure until a call was received from another facility. The resident was brought back to the facility by the Administrator and the DON, who did not consider it an elopement because the resident had signed out and was deemed cognitively intact by the DON. However, staff interviews revealed that the resident was known to attempt to leave the facility daily and required redirection, indicating a lack of awareness and supervision by the facility staff. The facility's failure to report the incident to the State Agency was based on the belief that it was not an elopement due to the resident signing out. However, staff members, including a CNA and an LVN, expressed concerns about the resident's cognitive ability to make safe decisions and the potential risk of harm. The facility's policy did not address reporting elopements to the State, and the incident was not reported as required by HHSC guidelines, which mandate reporting emergency situations that pose a threat to resident health and safety within 24 hours.
Failure to Implement Hospital Orders for Diabetes Management
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not implement hospital orders for blood glucose monitoring four times a day and administering sliding scale insulin four times a day upon the resident's admission. This lapse in care persisted from the resident's admission date until two weeks later, during which time the resident experienced elevated blood sugar levels and expressed concerns about his diabetes management. The resident, who was admitted with diagnoses including type II diabetes, had a hospital discharge summary indicating the need for insulin administration based on a sliding scale. However, the facility's records showed that the resident's blood sugar was only monitored twice a day, and insulin was not administered according to the hospital's instructions. The resident reported feeling unwell and expressed worry about his diabetes management, noting that he had asked the nursing staff about his insulin but did not receive satisfactory responses. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's elevated blood sugar levels. The LVN was unsure why the resident had not been on insulin earlier, and the NP stated she was not informed of the elevated blood sugar levels until much later. The DON acknowledged that hospital orders should have been implemented after the NP's review and that the nurses should have notified the NP about the resident's elevated blood sugar levels. The facility did not provide policies on physician notifications and new admissions/orders from the hospital when requested.
Medication Administration Delays
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications to meet the needs of each resident. Specifically, two residents experienced significant delays in receiving their scheduled medications over a period of several days. These delays ranged from 2.5 to 6 hours past the ordered times, affecting medications critical for managing conditions such as pain, anxiety, and respiratory support. One resident, a cognitively intact female with a history of type II diabetes, depression, asthma, and a femur fracture, reported that her medications were consistently administered late. This included medications for pain, anxiety, and other conditions, which she stated led to heightened symptoms of pain and anxiety. The resident's medication administration records confirmed multiple instances of late administration, including significant delays in the morning and afternoon doses. Another resident, also cognitively intact, with diagnoses of hypertension, scoliosis, and rheumatoid arthritis, experienced delays in receiving pain and respiratory medications. Although this resident reported that the delays did not always affect her, the medication administration records showed that her treatments were administered several hours late on multiple occasions. Interviews with facility staff revealed that the facility did not adhere to the standard one-hour window for medication administration, opting instead for a more liberal approach, which contributed to the delays.
Significant Medication Errors Due to Delayed Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who experienced delays in receiving their prescribed medications. Resident #1, a cognitively intact female with multiple diagnoses including type II diabetes, depression, asthma, and a femur fracture, did not receive her scheduled medications on time from June 24 to June 27, 2024. The medications, which included those for pain, anxiety, and other conditions, were administered between 2.5 to 6 hours late. Resident #1 reported that the delays in receiving her pain and anxiety medications significantly affected her, causing heightened symptoms. Similarly, Resident #2, also cognitively intact and diagnosed with hypertension, scoliosis, and rheumatoid arthritis, experienced delays in receiving her medications. Her pain and respiratory support medications were administered late on multiple occasions, with delays ranging from 3 to 5 hours. Although Resident #2 stated that the delays did not always affect her, the facility's failure to administer medications on time was evident. Interviews with staff revealed that the facility did not adhere to the standard practice of administering medications within one hour before or after the scheduled time. The Medication Aide (MA) acknowledged difficulties in meeting this timeframe, while the Administrator (ADM) admitted that significant delays in administering pain, anxiety, or breathing treatments were not acceptable. The facility's policy required medications to be administered as prescribed, yet the liberal medication pass approach contributed to the observed deficiencies.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in its kitchen, as observed during a survey. The deficiencies included improper labeling and dating of food items, inadequate sanitization of dishes, and improper storage of employee personal food items alongside resident food items. These failures were identified during observations of the walk-in refrigerator, where several food items were found unlabeled and undated, and employee lunches were stored without separation from resident food items. The dishwashing process was also found to be deficient, with the sanitizer concentration in the dish machine measuring below the required 50 ppm. Despite the dish machine being serviced recently, the concentration remained at 25 ppm during multiple checks. The Dietary Supervisor acknowledged the issue and mentioned that a technician had been called to address it. However, staff continued to use the dish machine for washing and sanitizing dishes, contrary to the expected protocol of using alternative methods like the three-compartment sink or paper products when the dish machine was not functioning properly. Interviews with the Dietary Supervisor and the Registered Dietitian Nutritionist (RDN) revealed a lack of consistent training and monitoring of the dish machine's operation. The RDN had previously identified issues with the dish machine and had communicated these concerns to the facility's administration. However, the Dietary Supervisor, who was relatively new, did not check the dish machine daily and relied on staff to do so. The facility's monthly kitchen sanitation audits also reflected ongoing issues with labeling and dating of food items and incomplete dish machine logs, indicating a systemic problem in maintaining food safety standards.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure personal privacy for residents during care, as observed in the actions of several staff members, including MDS B, LVN C, CNA G, CNA H, and CNA J. These staff members entered the rooms of two residents without knocking or announcing themselves, which is a violation of the facility's policy on resident privacy. Specifically, CNA H was observed entering a resident's room without knocking while offering water, and LVN C entered another resident's room without announcing himself. Similar actions were noted with CNA J, who entered rooms to collect lunch trays, and MDS B and CNA G, who also failed to knock or announce themselves before entering residents' rooms. Interviews with the involved staff revealed that they had been trained on resident rights and privacy, and they acknowledged the importance of knocking and announcing themselves to respect residents' privacy and maintain a homelike environment. However, reasons for not adhering to this practice varied, including forgetfulness and assumptions about residents' needs. The facility's Administrator and DON emphasized the importance of this practice to ensure residents feel respected and comfortable in their living environment. The facility's policy on dignity and respect clearly states that staff should knock before entering a resident's room, highlighting the deficiency in practice observed during the survey.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary personal hygiene services to residents who were unable to perform activities of daily living independently. Specifically, Resident #70, a female with minimally impaired cognition, expressed a desire for her fingernails to be trimmed, but this was not done despite her requests. Observations showed her nails were long, and staff acknowledged the need for trimming but did not follow through. Similarly, Resident #8, a male with severely impaired cognition, had dirty and untrimmed fingernails, and there was no regular schedule for nail care, leading to neglect in maintaining his personal hygiene. Resident #83, a female with severely impaired cognition, had long, thick, and jagged toenails, which were not addressed by the staff. Despite the presence of a CNA in her room, the toenails were not trimmed, and there was confusion about whether hospice or facility staff were responsible for her nail care. Additionally, Resident #4, a female with severely impaired cognition, had noticeable facial hair that was not shaved, despite her family member's comments about her appearance. The staff did not consult with the family or take action to address her grooming needs. Interviews with staff, including CNAs and the DON, revealed inconsistencies in the provision of nail care and shaving services. There was a lack of documentation for refusals of care, and staff were unclear about their responsibilities and the procedures for addressing residents' personal hygiene needs. The facility's policy emphasized the importance of maintaining residents' dignity and quality of life, but the observed deficiencies indicated a failure to adhere to these standards.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to discrepancies in their discharge records. Resident #96's discharge Minimum Data Set (MDS) inaccurately indicated that she was discharged to a Short Term General Hospital, while in reality, she was discharged home against medical advice (AMA). This error was identified through a review of the resident's face sheet, nursing progress notes, and an interview with the resident's family member, who confirmed that the resident left the facility with them and was not hospitalized. Similarly, Resident #97's discharge MDS incorrectly stated that he was discharged home, whereas he was actually transferred to an acute care hospital for further medical treatment. This was corroborated by nursing progress notes that documented the resident's transfer to the hospital for a paracentesis and subsequent admission for bronchitis. Interviews with the MDS coordinator and the Director of Nursing (DON) confirmed the inaccuracies in the MDS assessments for both residents. The MDS coordinator acknowledged the responsibility for ensuring the accuracy of the MDS assessments and was observed correcting the errors. The facility's policy mandates comprehensive and accurate assessments, which were not adhered to in these cases, potentially affecting the residents' care and quality of life. The Administrator emphasized the importance of accurate MDS assessments, as inaccuracies could lead to incorrect information being used for care planning and payment purposes.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide individualized activities to a resident, leading to a deficiency in meeting the resident's physical, mental, and psychosocial well-being needs. The resident, a male with dementia, muscle wasting, and adjustment disorder, was observed to have little interest in activities and exhibited symptoms of depression. Despite having a care plan that included goals and interventions for activity involvement, the resident's participation in activities was minimal, and there was a lack of documentation regarding encouragement or refusals of activities. Interviews with staff and family members revealed that the resident enjoyed physical activities and had a history of being a mechanic, indicating a preference for tinkering and outdoor activities. However, the resident was often found sleeping in bed, and staff reported difficulties in motivating him to participate in activities. The activity staff and therapy team provided some one-on-one activities, but these were infrequent, and there was no evidence of consistent encouragement or engagement in activities that aligned with the resident's interests. The facility's policies on activities and nursing services emphasized the importance of providing activities based on residents' preferences and maintaining their quality of life. However, the lack of regular, individualized activities for the resident, as well as insufficient documentation of activity participation, highlighted a failure to adhere to these policies. This deficiency placed the resident at risk of decreased well-being, as noted in the report.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide the physician-prescribed therapeutic diet to Resident #298, who was supposed to be on a no salt added diet due to her medical conditions, including atrial fibrillation, severe protein-calorie malnutrition, chronic diastolic heart failure, morbid obesity, and high blood pressure. Despite the dietary order specifying no salt added, observations revealed that Resident #298 received meals with salt packets, and her meal tickets did not reflect the no salt added requirement. Interviews with staff, including LVNs and the Dietary Supervisor, indicated a lack of awareness and communication regarding the resident's dietary needs, with the dietary slip failing to mention the no salt added diet. The process for updating dietary orders involved communication slips, but there was a disconnect between the orders and what was communicated to the dietary staff. The Dietary Supervisor relied on receiving a yellow diet slip to know the resident's dietary needs, but the slip for Resident #298 only mentioned a house shake at lunch and dinner, omitting the no salt added requirement. The Director of Nursing confirmed that dietary orders were supposed to be communicated clearly, but the system did not notify staff of pending orders, leading to potential oversights. This failure to provide the correct diet placed Resident #298 at risk for health complications related to her heart condition.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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