Paradigm At Faith Memorial
Inspection history, citations, penalties and survey trends for this long-term care facility in Pasadena, Texas.
- Location
- 811 Garner Rd, Pasadena, Texas 77502
- CMS Provider Number
- 675321
- Inspections on file
- 31
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Paradigm At Faith Memorial during CMS and state inspections, most recent first.
A resident with severe dementia, PTSD, and a history of behavioral episodes became agitated during a noisy overnight shift when fireworks and gunshots in the neighborhood disturbed multiple residents. A CNA later reported to another CNA that the resident had approached the nurse’s station and raised a hand as if to hit, and that the CNA responded by cursing at the resident and threatening to "show" the resident if struck. The second CNA did not immediately report this allegation of verbal abuse despite regular ANE training and only disclosed it later in response to a DON inquiry. The facility did not report this abuse allegation to the state survey agency within the required 5-working-day timeframe, resulting in a deficiency for failure to timely report suspected abuse.
A resident with serious mental illness, moderate cognitive impairment, bowel incontinence, and documented feces-smearing behavior experienced multiple episodes where feces were on his hands, under his fingernails, on his face, beard, sides of his mouth, teeth, and pillow, and in or around his mouth. A medication aide/CNA saw the resident reach into his brief, pull out feces, and attempt to put his soiled hand into his mouth, cleaned him, but did not document or report the incident. A PTA observed the resident with feces on his hands, facial hair, and in his teeth, cleaned his hands, and verbally informed an LVN and the rehab director, but there was no clear documentation or escalation to nursing leadership. An anonymous report stated an LVN entered the room after being told the resident had feces on his hand, refused to address the situation, and left, while another staff member partially cleaned the resident. Nursing leadership and the resident’s primary nurse reported they were not informed of these behaviors at the time, despite an existing care plan for feces smearing and a facility infection control policy requiring surveillance, reporting, and QAPI oversight, resulting in a cited failure to maintain an effective infection prevention and control program.
A resident with severe dementia, PTSD, and a history of behavioral episodes lived on a secure unit and was highly sensitive to loud noises and perceived threats. During a period of increased agitation related to neighborhood fireworks and gunshots, a CNA reported that the resident came around the nurse’s station and tried to hit her, and in response she cursed at and threatened the resident using profane language. Another CNA later confirmed that this statement was made but did not immediately report it. Bruising was subsequently observed on the resident’s right hand and forearm by nursing staff, and a CNA acknowledged having seen the bruising earlier but assumed it was old and did not notify a nurse at that time. These actions and inactions, in the context of existing behavior-management and combative-resident policies and ongoing ANE training, resulted in a deficiency for failure to ensure the resident was free from verbal abuse and for delayed reporting of an observed injury and abuse allegation.
A resident with serious mental illness, moderate cognitive impairment, incontinence, and diarrhea exhibited repeated behaviors of reaching into a soiled brief and ending up with feces on the hands, under the fingernails, on the beard and around the mouth, and in the mouth and teeth. Multiple staff, including a medication aide, LVNs, and therapy staff, observed these episodes, but incidents were often not reported to the charge nurse or DON, not consistently documented as a change in condition, and not communicated to the physician or family. The existing care plan addressed PASRR-positive mental illness and later referenced feces smearing but did not specifically include the behavior of digging into the brief and contaminating the mouth, nor did it contain detailed, measurable interventions and monitoring for this behavior. This resulted in the resident’s recurrent feces-related behaviors not being comprehensively assessed and incorporated into a person-centered care plan consistent with the resident’s medical, nursing, mental, and psychosocial needs.
A resident with schizoaffective disorder, bipolar disorder, and moderate cognitive impairment, who was incontinent and PASRR Level II, repeatedly dug into a soiled brief and ended up with feces on the hands, under the fingernails, on the face and beard, and in the mouth and teeth. Multiple staff, including a medication aide, an LVN, and a PTA, observed separate episodes where the resident attempted to put a feces-soiled hand into the mouth or was found with feces on the hands and around the mouth, yet these incidents were not consistently documented, reported to the charge nurse, DON, or MD, and were not reflected as specific behaviors in the care plan. The resident’s primary nurse reported she had not been informed of these behaviors and would have treated them as a change in condition requiring MD notification, while leadership confirmed they were unaware of any MD notification regarding feces in or on the resident’s mouth, despite facility policies requiring prompt reporting of condition changes and adherence to infection control and standards of care.
A resident who had left the facility with family was documented as having received multiple medications on several dates after their departure. Staff interviews confirmed the resident did not return, yet medication aides continued to record medication administration in the electronic medical record. The facility's policy required staff to flag the MAR and follow guidelines when a resident was not present, but this was not followed, resulting in inaccurate medical records.
Two residents with indwelling urinary catheters did not receive catheter changes as ordered and per facility expectations, and documentation of catheter changes was absent over multiple months. One resident’s catheter bag showed an installation date several weeks prior, with brown discoloration and odor, and the resident reported anxiety about the lack of catheter changes. Another resident with a suprapubic catheter had an order for monthly changes, but observations showed the same bag in place for an extended period, and this resident was later treated with oral antibiotics for a UTI. Nursing leadership stated that nurses were responsible for changing catheters every 30 days and as needed, and that such changes should be documented on the MAR/TAR, which did not occur in these cases.
A resident with paraplegia, moderate cognitive impairment, and chronic lower back pain had an order for Acetaminophen-Codeine 300-30 mg every 8 hours, but MAR reviews over several months showed multiple doses marked with a code indicating "Other/See Progress Notes" without corresponding documentation that the medication was given. The resident reported that this occurred repeatedly, that staff told her the medication was not available and blamed the pharmacy, and that she experienced significant pain and inability to sleep when she did not receive her pain medication. A medication aide stated she would document code 8 when the narcotic was not available and she had notified a nurse, while nursing staff and the ADON described processes for reordering narcotics and use of the automated dispensing system but could not explain the specific missed or undocumented doses, despite facility policy requiring medications to be administered as prescribed.
A resident with vascular dementia eloped from a facility due to inadequate supervision and an unsecured side door. The resident, who was severely cognitively impaired, was missing for about an hour before being found by police. The facility failed to conduct an elopement risk assessment upon admission, and staff did not notice the resident was missing until informed by a family member.
The facility failed to maintain the required RN coverage of eight consecutive hours per day, seven days a week, on four occasions in September 2024. Interviews and record reviews revealed that RNs did not work the necessary hours, and there were incidents of falls and aggression on some of these days. The DON and Administrator were not aware of the issue due to their recent employment, and changes in human resources personnel may have contributed to the oversight.
The facility failed to transmit MDS data to the CMS System within 14 days for two residents, leading to potential delays in care plans and payment issues. The MDS coordinator cited waiting for RN signatures and staff turnover as reasons for the delay.
A resident with severe cognitive impairment and multiple health conditions complained of tooth pain and difficulty chewing, but the facility failed to refer her to a dentist. Despite the resident's care plan indicating dental concerns, staff did not take appropriate action to address her needs. The DON was new and unaware of the issue, the LVN provided only pain medication, and the SW was out of the facility, leading to a lack of communication and follow-up.
The facility failed to label and date leftover food items in the kitchen, and staff improperly stored personal food, violating professional standards for food safety. Additionally, the stove door was broken and inadequately repaired. These issues were confirmed through staff interviews and observations.
A resident with severe cognitive impairment and urinary issues removed her catheter drainage bag, which was not replaced by the nursing staff before she was sent to the hospital. The nurse prioritized the resident's immediate safety after she was found on the floor, and the difficulty in accessing a new bag was cited. The DON acknowledged the expectation to replace the bag to prevent potential pathogen exposure.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a subdural hematoma. Despite visible injuries, the resident was sent to the hospital via non-emergency transport, causing a 2.5-hour delay in care. The facility failed to follow its fall management policy, contributing to the deficiency.
Failure to Timely Report Verbal Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state survey agency within 5 working days of the incident. A CNA (CNA A) was alleged to have cursed at and threatened a resident with severe cognitive impairment and PTSD during an overnight shift, and this allegation was not immediately reported by the CNA who learned of it (CNA B), nor was it reported to the state agency within the required timeframe. The report states that this failure to report could place residents at risk for abuse, neglect, exploitation, and/or mistreatment. The resident involved was an older adult with vascular dementia (severe), anxiety, dysphagia, hypertension, hyperlipidemia, cognitive communication deficit, depression, anxiety disorder, PTSD, ataxic gait, lack of coordination, psychotic disorder with delusions, and restlessness and agitation. The resident’s BIMS score was 3/15, indicating severe cognitive impairment, and the care plan documented a history of behavioral episodes including cursing, yelling, hitting other residents, pushing, and attempts to hit staff. The resident required a secure unit and had known sensitivity to noise, yelling, and commotion, which triggered PTSD and aggressive or exit-seeking behaviors. According to interviews and text records, CNA A worked the secure unit on the nights of 12/30 and 12/31 while the facility was short-staffed, caring for approximately 30 residents amid loud fireworks and gunshots in the neighborhood that caused widespread agitation and exit-seeking among residents. CNA B later reported to the DON via text that CNA A had described an encounter in which the resident approached the nurse’s station, raised his hand, and tried to hit CNA A, and that CNA A responded by saying, “Mother fucker you better not hit me or I'm gonna show you.” CNA B acknowledged in interview that she did not immediately report this verbal abuse allegation when she first learned of it from CNA A and stated she should have reported it right away. The facility’s investigation materials and interviews confirm that the allegation of verbal abuse was not reported to the state survey agency within 5 working days of the incident, constituting the cited deficiency. In addition, documentation and interviews show that bruising was later observed on the resident’s right hand and forearm, with RN A identifying the discoloration during morning rounds and documenting it as a change in condition, notifying the MD and responsible party, and obtaining an x-ray that showed osteoporosis but no fracture or dislocation. CNA B’s written statement indicated she had noticed bruising on the resident’s right forearm while providing care on a later shift but assumed it was old and did not report it at that time. While the cause of the bruising could not be determined, the core cited deficiency in the report is the facility’s failure to timely report the verbal abuse allegation involving CNA A and the resident to the state survey agency within the required 5-working-day period.
Failure to Implement Infection Control Measures for Resident With Feces-Smearing Behavior
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program for a resident with known feces-smearing behavior. The resident was an adult male with schizoaffective disorder, bipolar disorder, depressive type, GERD, bowel and bladder incontinence, social isolation, and a PASRR Level II for serious mental illness. His MDS showed moderate cognitive impairment and a need for assistance with toileting. The care plan identified a focus on behaviors of eating or smearing feces, with goals and interventions related to monitoring behaviors, explaining procedures, encouraging activities, and reporting changes to the MD. Despite this, multiple episodes occurred in which the resident had feces on his hands, under his fingernails, on his face, beard, sides of his mouth, teeth, and pillow, and in or around his mouth, without consistent reporting or documentation to nursing or leadership. On one occasion, a medication aide who was also a CNA observed the resident during a medication pass placing his hand into his adult brief, pulling out feces, and attempting to put his soiled hand into his mouth. She intervened, cleaned the resident, changed his brief, and repositioned him, but did not document or report the incident to the charge nurse, assuming the behavior had already been reported. In another incident, a PTA entered the resident’s room around lunchtime and observed soiled hands, a fecal odor, and a brown tinge in the resident’s mustache, beard, chin, and teeth, with fecal odor from the resident’s mouth. The PTA cleaned the resident’s hands and fingernails, reported the situation to an LVN and to the Director of Rehabilitation, but there is no indication that this episode was documented in the medical record or that it was reported up the nursing chain as a change in condition. An anonymous source reported that the resident was known to have feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth on a recurring basis, and that a non-direct care male staff member had notified an LVN after seeing feces on the resident’s hand. According to this account, the LVN entered the room, observed the condition, stated she was not dealing with it, and left the resident as he was, after which the male staff washed the resident’s hands but could not complete full cleaning due to other duties. The LVN later stated she had been called to the room by the PTA, saw what she thought was dried chocolate on the resident’s hands, mouth, and pillow, and only later realized it was feces when the resident identified it as “poop.” She stated she called an aide to clean the resident but did not notify the resident’s nurse or MD, assuming the information had already been relayed, and believed she had documented the incident, though no such documentation was confirmed in the report. The resident himself reported episodes of diarrhea, digging in his brief, finding feces on his hands and under his fingernails, and then unknowingly rubbing his face and beard, sometimes getting feces into or around his mouth, and stated he relied on staff to clean him and change his brief and sheets afterward. Nursing leadership, including the ADM and DON, reported initially being unaware of the resident’s behavior of digging in his brief and getting feces on his hands and mouth, and the resident’s primary nurse (an LVN) stated she had not been informed of any such episodes. The ADON, who served as the infection preventionist, stated she was informed that the resident had smeared feces but only later learned that feces had been in his mouth and beard. The MDS nurse reported she care planned for feces smearing once informed but would have escalated to an IDT meeting and broader notifications had she known feces were in and around the resident’s mouth. The facility’s written infection control policy required a comprehensive infection control program with surveillance, reporting, education, and QAPI oversight, but the repeated failure of multiple staff (including an LVN, a medication aide/CNA, and a PTA) to consistently recognize, document, and report these feces-related incidents to the resident’s nurse and leadership led to the cited deficiency in infection prevention and control. Additionally, the resident had an active order for PRN ondansetron for nausea and vomiting, but the MAR for December and January showed no doses administered as of early January, despite the resident’s report of diarrhea and the NP and MD notes documenting loose stools and diarrhea. The MD ordered labs to monitor for dehydration and electrolyte imbalance, and the NP documented a chief complaint of diarrhea, but there was no documentation of ondansetron use. While the primary deficiency centers on infection control, these clinical details underscore that the resident was experiencing ongoing gastrointestinal symptoms at the time the feces-smearing and oral contamination behaviors were occurring, and that staff were aware of his diarrhea and incontinence but did not consistently integrate this information into infection control surveillance and reporting as required by the facility’s infection control program.
Failure to Protect Cognitively Impaired Resident From Verbal Abuse and Delayed Reporting of Injury
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. The resident was an older adult with severe vascular dementia, PTSD, anxiety, depression, psychotic disorder with delusions, cognitive communication deficit, ataxic gait, and a history of behavioral episodes including hitting and pushing other residents and attempting to hit staff. His BIMS score was 3/15, indicating severe cognitive impairment, and he resided on a secure unit with care plans addressing behavior management, need for a secure environment, impaired cognition, and anticoagulant-related bruising risk. On the dates in question, the resident was known to be easily provoked by verbal aggression, loud noises, and hostility, and was particularly sensitive to environmental triggers such as fireworks and gunshots, which caused agitation and exit-seeking behaviors. According to interviews and text-message documentation, CNA A reported to CNA B that during an overnight shift on the secure unit, the resident came around the nurse’s station and tried to hit her. In response, CNA A told the resident, “Mother fucker, you better not hit me or I’m going to show you,” which constituted cursing at and threatening the resident. CNA B later confirmed in an interview and in text communication with the DON that CNA A had cussed and threatened the resident using those words. RN B described CNA A as having a loud and assertive personality that the resident did not like, and stated that the resident was extremely agitated and exit-seeking during the New Year’s Eve period due to fireworks and gunshots in the neighborhood. The facility’s behavior management and combative resident policies emphasized de-escalation, redirection, and therapeutic techniques, but there is no indication in the report that such approaches were used by CNA A during this encounter; instead, the interaction involved verbal aggression toward the resident. In addition to the verbal abuse, the report documents that bruising was later observed on the resident’s right hand and forearm. RN A first noted the bruising early in the morning during rounds, describing purple discoloration from the top of the hand to the wrist, a white area, and then purple discoloration on the forearm, with no open areas, edema, or reported pain. The resident was unable to explain how the bruising occurred. CNA B stated she had noticed bruising on the resident’s right forearm while providing care on a prior shift but assumed it was old and did not report it to a nurse at that time. The DON and ADM stated that CNA B had observed the bruising and failed to report it, and that CNA B also did not immediately report the allegation that CNA A had cussed at and threatened the resident. The physician, family, and staff interviews acknowledged the resident’s PTSD, sensitivity to loud noises and dominance, and tendency to lash out or swing his arms protectively when feeling threatened, but the cause of the bruising was not determined within the report. The deficiency centers on the facility’s failure to ensure the resident was free from verbal abuse by staff and the associated failure of timely reporting by staff who became aware of the abusive statement and the bruising. The facility’s own policies on behavior management and care of combative residents required comprehensive assessment, recognition of behavioral triggers, use of non-pharmacological interventions such as redirection and de-escalation, and prompt reporting of changes in behavior or condition to licensed staff and appropriate parties. Despite these policies and ongoing in-service training on abuse, neglect, and exploitation, the documented events show that a CNA used profane and threatening language toward a cognitively impaired, behaviorally vulnerable resident, and another CNA delayed reporting both the verbal abuse and the observed bruising. These actions and inactions directly led to the cited deficiency for failure to ensure the resident was free from abuse. The report also notes that the resident’s care plan included specific behavioral incidents over time, such as cursing, yelling, hitting other residents, and attempting to hit staff, with interventions including psychiatric evaluation, separation from other residents, attempts to move him to quieter areas, distraction, and behavior control techniques like redirection and calming. Staff interviews, including those of the DON, RNs, and the physician, consistently described the resident as highly sensitive to loud noises and perceived threats, with fireworks and gunshots on New Year’s Eve exacerbating his agitation and exit-seeking. Nonetheless, during the incident in question, the CNA’s response to the resident’s approach and attempted strike was not consistent with the resident’s identified needs or the facility’s policies, resulting in the resident being subjected to verbal abuse. Overall, the deficiency is based on the facility’s failure to ensure that the resident was free from verbal abuse by staff and the failure of staff to promptly report both the abusive interaction and the subsequent bruising observed on the resident’s wrist and forearm. These failures occurred in the context of a resident with severe cognitive impairment, PTSD, and a documented history of behavioral issues, whose care plan and diagnoses required careful, non-threatening behavioral management and adherence to abuse-prevention and reporting requirements.
Failure to Develop and Implement Comprehensive Care Plan for Recurrent Feces-Related Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to address a resident’s identified behavioral and infection-control-related needs. The resident was an adult male with bipolar disorder, schizoaffective disorder (depressive type), GERD, and a PASRR Level II for serious mental illness. His MDS showed moderate cognitive impairment (BIMS 11/15), and he was incontinent of bowel and bladder and required assistance with toileting. Despite these factors and a documented care plan focus on PASRR-positive mental illness and a later focus on increased episodes of smearing feces, the care plan did not include specific, focused behaviors related to digging in his soiled brief, eating, or smearing feces, nor did it outline clear, measurable interventions and monitoring for these behaviors. Multiple staff observations and interviews described repeated episodes of the resident having feces on his hands, under his fingernails, on his beard and around his mouth, and in his mouth and teeth, associated with him reaching into his soiled brief. A medication aide reported seeing the resident place his hand into his brief, remove feces, and almost place his soiled hand into his mouth before she intervened; she cleaned him but did not report the incident to the charge nurse, assuming it was already care planned. An anonymous individual reported that during a holiday week, the resident was repeatedly seen with feces on his hands, beard, sides of his mouth, and in his mouth and teeth, and that an LVN entered the room, stated she would not deal with the situation, and left without addressing or reporting it, leaving non-care staff to attempt cleanup. A physical therapist assistant described entering the resident’s room and finding feces on the resident’s hands, facial hair, chin, and in his mouth and on his teeth, with a strong fecal odor, and stated this was not the first such incident he had observed. Nursing staff interviews further demonstrated that these behaviors were not consistently recognized, documented, or communicated as a change in condition requiring care plan revision. The resident himself reported repeated days of diarrhea and that he sometimes reached to the back of his brief due to discomfort, later realizing his hands and fingernails were soiled and that he would unknowingly rub his hands on his face, resulting in feces on his beard and near his mouth, describing this as a repeated pattern. The DON and administrator stated they had not been made aware of ongoing behaviors of the resident digging into his soiled brief and putting feces on or in his mouth, and the DON acknowledged that if they had known it was more than a one-time occurrence, it should have been care planned and documented in progress notes. LVNs interviewed stated they were not informed of the feces-related behaviors and indicated that, had they been aware, they would have reported them as a change in condition to the MD and leadership and expected psychiatric evaluation orders and care plan updates. The MDS nurse confirmed that the care plan was only updated to reflect feces smearing after she was informed, and that she had not known about feces in and around the resident’s mouth, which would have prompted a broader IDT care conference and notifications. Collectively, these findings show that the resident’s recurrent behavior of digging into his soiled brief and contaminating his hands and mouth was not comprehensively assessed, documented, communicated, or incorporated into a detailed, measurable care plan consistent with his assessed medical, nursing, mental, and psychosocial needs. The facility’s own baseline care plan policy required that a baseline care plan be developed within 48 hours of admission and that updates to the resident’s plan of care be made in the comprehensive care plan, including PASRR recommendations and changes in condition. Despite this, the resident’s care plan did not initially address the specific behavior of digging into his brief and contaminating his hands and mouth with feces, even after multiple staff observed such incidents. Staff interviews revealed missed opportunities to recognize and report these behaviors as changes in condition, inconsistent assumptions that the behavior was already care planned, and lack of timely documentation in progress notes. As a result, the resident’s recurrent feces-related behaviors, in the context of his mental illness, cognitive impairment, incontinence, and diarrhea, were not translated into a comprehensive, person-centered care plan with clear, measurable interventions and monitoring, as required by regulation and the facility’s own policy. Additionally, the resident’s responsible party reported not being informed of any abnormal behaviors, and some staff acknowledged uncertainty about whether the behavior required reporting or additional interventions. The assistant DON, who also served as infection preventionist, stated that the occurrence constituted a change in condition that required MD notification and that interventions such as increased rounds and more frequent brief changes were expected, but the report shows that these expectations were not consistently met prior to the survey findings. The combination of repeated, observed feces-related behaviors, lack of consistent reporting and documentation, and the absence of a fully developed, behavior-specific care plan with measurable goals and timeframes demonstrates the facility’s failure to implement a comprehensive person-centered care plan that addressed the resident’s identified medical, nursing, mental, and psychosocial needs related to this behavior.
Failure to Report and Care Plan Repetitive Feces-Ingestion Behavior in Psychiatric Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services and to promptly notify the physician after significant changes in condition for a resident with serious mental illness. Resident #2, a male with diagnoses including schizoaffective disorder (depressive type), bipolar disorder, cognitive communication deficit, and GERD, had a PASRR Level II for serious mental illness and a BIMS score indicating moderate cognitive impairment. He required assistance with toileting and was incontinent of bowel and bladder. His care plan identified a PASRR-positive status and a risk for increased episodes and injury behaviors related to smearing feces, with goals for decreased behaviors through monitoring and interventions, but the care plan did not include focused behaviors related to digging in his brief, eating, or smearing feces. Resident #2 reported during interview that he had experienced repeated days of diarrhea and, due to discomfort, sometimes dug in his soiled brief, after which feces would be on his hands and under his fingernails. He stated he had rubbed his face, beard, sides of his mouth, and possibly placed his soiled hands in his mouth, and that this behavior had been an ongoing habit. He indicated he was often unaware his hands were soiled until after he had already put them in his mouth and did not recall calling staff for assistance, though he stated staff would clean him once they discovered he was soiled. Progress notes showed that on one date a NP evaluated him for diarrhea and an MD ordered monitoring for dehydration and electrolyte imbalance with labs, but there was no documentation of episodes involving feces on his hands, face, or in his mouth. Multiple staff interviews described specific incidents where Resident #2 was observed with feces on his hands, under his fingernails, on his face and beard, and in or around his mouth and teeth, which were not properly reported, documented, or communicated to his MD. A medication aide stated she saw the resident reach into his brief, pull out feces, and attempt to place his soiled hand into his mouth; she intervened, cleaned him, but did not document or report the incident, assuming it was already known and care planned. An anonymous person reported that around the New Year holiday, the resident had feces under his fingernails, on his hands, beard, sides of his mouth, and in his mouth and teeth, and that when an unknown male staff reported this to an LVN, the LVN allegedly refused to deal with it and left the room, with the incident going undocumented and without isolation or monitoring. The PTA reported entering the resident’s room and finding feces on his hands, in his facial hair, and in his mouth and teeth, with a fecal odor, and stated he notified an LVN and then personally cleaned the resident when no one returned; he also stated this was not the first such incident. Further interviews showed that the resident’s primary nurse (LVN A) was not informed of these behaviors and stated she would have reported them as a change in condition to the DON, administrator, and MD had she known. LVN B recalled being asked by the PTA to look at what she initially thought was chocolate under the resident’s fingernails and around his mouth; she cleaned him and educated him about using the call light but did not recognize it as feces at the time and did not report it to the MD, though she acknowledged such an incident would be a change in condition requiring immediate reporting. The administrator and DON stated they were not aware of any issues reported to the MD regarding feces in or on the resident’s mouth and acknowledged the behavior was not reflected in the care plan. Facility policies required that the MD and DON be notified of changes in condition and that infection control protocols and standards of care be followed, but the episodes of feces on and in the resident’s mouth, hands, and facial hair were not consistently reported, documented, or incorporated into his behavioral health care planning, leading to the cited deficiency.
Inaccurate Medication Administration Documentation for Absent Resident
Penalty
Summary
The facility failed to maintain accurate medical records for one resident who was reviewed for resident records. The resident, a male with a history of stroke and intact cognition, was documented as having left the facility with family and did not return. Despite this, the Medication Administration Record (MAR) showed that multiple medications were documented as administered to the resident on several dates after he had already left the facility. There were no nursing progress notes indicating the resident's return after his departure, and interviews with staff and the resident's family confirmed that he did not return to the facility during this period. Medication aides and nursing staff reported that they documented medication administration in the electronic medical record after giving medications, but could not recall if the resident was present at the time of documentation. The Director of Nursing and Unit Manager confirmed that staff were expected to chart medications immediately after administration and to ensure the resident was present. The facility's policy required staff to flag the MAR if a resident was not present and follow specific guidelines, which was not done in this case. This resulted in inaccurate documentation of medication administration for a resident who was not in the facility.
Failure to Perform and Document Timely Catheter Changes Resulting in UTI and Distress
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services to prevent urinary tract infections for residents with indwelling urinary catheters. For Resident #1, record review showed a physician’s order for an indwelling urinary catheter to be changed as needed for blockage and/or leaking, with a related care plan intervention to change the catheter, tubing, and bag per order. The care plan also noted a prior focus that the resident refused catheter changes. However, the August, September, and October 2025 Treatment Administration Records (TARs) contained no documentation of catheter changes, and progress notes did not document refusals or requests for catheter changes during that period. During observation and interview, Resident #1 reported that staff did not change her catheter every month and stated that staff became upset when she mentioned it. The resident showed the surveyor the urinary drainage bag, which had “8/28/25” written on it and contained brown discoloration; the resident also reported that the bag smelled and that, although she could not feel anything below the waist due to paraplegia, she felt anxious about the catheter not being changed. Later, the resident reported that staff changed her catheter on 10/11/25, and observation at that time showed a clean bag and tubing with no writing on the bag, but this change occurred after the period in which no changes were documented. For Resident #2, records showed a diagnosis including urinary retention and obstructive/reflux uropathy, with a physician’s order for a suprapubic indwelling urinary catheter to be changed monthly and as needed, starting 9/15/25. The September 2025 TAR documented a catheter change on 9/15/25 by LVN B. Observations on 10/9/25 and again on 10/13/25 showed the same notation on the urinary drainage bag indicating it was installed on “WED 8/27/25 14.00 HRS,” with no evidence of a subsequent bag change. Record review also showed physician orders for Macrobid and Levofloxacin for treatment of a UTI beginning on 10/13/25, and the care plan documented that the resident had frequent UTIs with an intervention for staff to provide catheter care every shift and as needed. Interviews with the Unit Manager and ADON confirmed that catheters were expected to be changed every 30 days and as needed per physician orders and that nurses were responsible for performing and documenting these changes.
Failure to Ensure Ordered Narcotic Pain Medication Was Administered and Properly Documented
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically Acetaminophen-Codeine 300-30 mg, as ordered for one resident. The resident was an adult female with paraplegia and chronic pain, admitted with a care plan that included anticipating her need for pain relief and responding immediately to any complaint of pain. Her quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment. Physician orders dated 2/24/25 directed that she receive Acetaminophen-Codeine 300-30 mg, one tablet by mouth every 8 hours for lower back pain. Review of the resident’s MARs for multiple months showed repeated use of code 8 (“Other/See Progress Notes”) in place of documented administration of the ordered Acetaminophen-Codeine doses. In May 2025, code 8 was documented for the 8 a.m. and 4 p.m. doses on 5/27/25; in June 2025, code 8 was documented on 6/28/25 at 8 a.m. and on 6/29/25 at 12 a.m., 8 a.m., and 4 p.m.; in August 2025, code 8 was documented on 8/31/25 at 8 a.m.; in September 2025, code 8 was documented on 9/30/25 at midnight; and in October 2025, code 8 was documented on 10/1/25 at midnight, 8 a.m., and 4 p.m. Review of the resident’s progress notes from 9/13/25 to 10/14/25 did not reveal any further documentation explaining the code 8 entries on 9/30/25 and 10/1/25 or confirming that the medication was administered at those times. In interviews, the resident stated that the facility was supposed to have her medication on time but reported that staff told her the medication was not available and blamed the pharmacy, and that this problem had been occurring monthly since the previous year. She reported that when she did not receive her pain medication, she felt terrible, could not sleep, her tailbone hurt, and she developed a headache. A medication aide reported that she usually administered Tylenol #3 to this resident twice a day, that she had to notify the nurse to reorder narcotics, and that if she documented code 8 on the MAR it meant she likely notified the nurse and did not give the medication because it was not available, possibly due to pharmacy delays; she could not recall the specific reason for the 8/31/25 entry and did not know where the nurse would document if the medication was given from the automated dispensing system. An LVN and the ADON both stated that nurses were responsible for reordering narcotics and denied problems with reordering, though the ADON acknowledged that if a narcotic was not refilled in time there could be unmanaged pain and that the Tylenol #3 was available in the automated dispensing system, but could not explain why the medication was not given. The facility’s policy stated that medications shall be administered as prescribed by the attending physician.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident diagnosed with vascular dementia, who eloped from the facility to a nearby tire shop. The resident, who was severely cognitively impaired, was missing for about an hour before being found by police and returned to the facility. The incident occurred because the resident exited through a side door that was not alarmed and was not part of the facility's secured unit. Staff did not notice the resident was missing until a family member called to inform them. The resident's admission records did not include an elopement risk assessment, which should have been completed upon admission. The resident had no documented history of wandering or exit-seeking behaviors prior to the incident. On the day of the elopement, the resident was last seen by a CNA around 6:00 pm, and staff did not realize the resident was missing until 6:30 pm when the family member called. The facility's daily sign-in sheet indicated that staff worked 12-hour shifts, and the resident was under the care of various staff members throughout the day. The facility's elopement policy required routine elopement risk assessments and appropriate supervision, which were not adequately followed in this case. The facility's incident and accident report confirmed that this was the only elopement incident involving the resident from August 2024 through February 2025. The lack of an elopement risk assessment and the unsecured side door contributed to the resident's ability to leave the facility unnoticed.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, as required. This deficiency was noted on four specific days in September 2024: the 1st, 14th, 15th, and 29th. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility did not have adequate RN coverage on these days. The DON, who started in October 2024, was not present during the time of the deficiency, and the Administrator, who began in December 2024, was unaware of any issues prior to her tenure. The facility's human resources department, responsible for completing the PBJ report, had a change in personnel, which may have contributed to the oversight. Record reviews confirmed that on the specified dates, the RNs did not work the required eight consecutive hours. For instance, RN H and RN G worked partial shifts that did not meet the eight-hour requirement. Additionally, the facility's incident reports indicated that there were fall incidents and episodes of physical aggression on some of these dates, although there was no documented increase in incidents compared to the rest of the month. The lack of consistent RN coverage could potentially place residents at risk of not receiving adequate care, as RNs are essential for performing necessary assessments.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to transmit encoded, accurate, and complete Minimum Data Set (MDS) data to the CMS System within the required 14 days after completing the resident's assessment for two residents. For one resident, the Admission MDS assessment was completed 16 days after admission, exceeding the required timeframe. Another resident's Discharge MDS assessment was completed 24 days after the required completion date. These delays in transmitting MDS data could potentially impact the timely completion of care plans and result in denial of services or payment. Interviews with facility staff revealed that the MDS coordinator completed the assessments as required but had to wait for RN signatures, which contributed to the delay in transmission. The MDS coordinator also mentioned that the discharge MDS for one resident was not completed in a timely manner because it was initially done by a staff member who no longer worked at the facility. The Director of Nursing (DON) stated that she was not trained to sign the MDS, and a corporate staff member was responsible for signing off on the MDS. The facility's policy on MDS completion and transmission was requested, and the MDS coordinator indicated adherence to the RAI manual.
Failure to Provide Routine Dental Care for Resident
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, which was identified during a survey. The resident, a female with severe cognitive impairment and multiple health conditions, including pain and dementia, complained of tooth pain and difficulty chewing. Despite these complaints, the resident was not referred to a dentist. The resident's care plan indicated dental concerns and a risk for increased pain and infections, but no action was taken to address her dental needs. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's dental care needs. The Director of Nursing (DON) was new and unaware of the resident's dental issues, while the Licensed Vocational Nurse (LVN) acknowledged the resident's complaints of mouth pain but only provided pain medication without referring her to a dentist. The Social Worker (SW) was also unaware of the resident's need for dental services due to being out of the facility for an extended period. The facility's policy stated that dental services are the responsibility of the resident or Medicaid, but it did not address situations where the facility would cover costs if a resident was in pain.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, the facility did not label and date leftover food items in three coolers, which included coleslaw, tuna, a brown substance, pudding, and Jello. Additionally, food brought from home by staff was not labeled, dated, or stored in a designated refrigerator outside the kitchen. These practices were identified through observations and interviews with kitchen staff, including a cook and the Dietary Manager, who acknowledged the lapses in labeling and dating food items. Further issues were noted with the kitchen equipment, as the stove door was broken and temporarily held in place with cardboard. The Dietary Manager confirmed that the stove door had been broken since around Christmas and had informed the Maintenance Manager, who no longer worked at the facility, but did not document the conversation. Interviews with the Dietary Aide and the facility's Administrator revealed that staff were aware of the policy against storing personal food in the kitchen cooler, yet the policy was not followed. The facility's policy on food safety emphasized the importance of labeling and dating food to prevent contamination and bacterial growth.
Failure to Replace Catheter Bag After Removal
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, specifically in replacing a foley catheter drainage bag after it was removed by the resident. The resident, a female with severe cognitive impairment and medical conditions including urine retention and obstructive uropathy, pulled off her catheter drainage bag. A CNA reported the incident to a nurse, who prioritized assessing the resident's safety after she was found on the floor, rather than replacing the catheter bag. The nurse did not replace the catheter bag before the resident was sent to the hospital, citing the need to focus on the resident's immediate safety and the difficulty in accessing a new bag due to a locked supply closet. The Director of Nursing (DON) acknowledged that the catheter bag was on the floor and that the nurse was focused on the resident's neurological status and calling emergency services after the resident hit her head. The DON stated that the expectation would have been to replace the catheter bag to ensure proper drainage and prevent potential exposure to pathogens. The facility's policy requires nursing staff to demonstrate competencies necessary to care for residents, which was not adhered to in this instance, potentially placing the resident at risk for urinary tract infections.
Delayed Emergency Response After Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received timely emergency care following an unwitnessed fall, which resulted in a subdural hematoma. The resident, who had severe cognitive impairment and was at risk for falls due to dementia and other conditions, was found on the floor with a head injury. Despite the presence of a bump over the left eye and a split lip, the resident was sent to the hospital via non-emergency transport, leading to a 2.5-hour delay in receiving care. Interviews with staff revealed that the LVN on duty assessed the resident and determined that the vitals were stable, opting for non-emergency transport based on previous fall incidents and the resident's baseline condition. The LVN was not trained to document neuro checks and did not perceive the situation as requiring immediate emergency services. The facility's policy required emergency services to be initiated if a fall was life-threatening, but this protocol was not followed. The delay in emergency care was identified as an Immediate Jeopardy situation, indicating a significant risk to the resident's health and safety. The facility's failure to adhere to its fall management policy and the lack of proper training and documentation contributed to the deficiency, placing the resident at risk for further injury.
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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