Paradigm At Kountze
Inspection history, citations, penalties and survey trends for this long-term care facility in Kountze, Texas.
- Location
- 604 Fm 1293, Kountze, Texas 77625
- CMS Provider Number
- 455594
- Inspections on file
- 24
- Latest survey
- August 13, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Paradigm At Kountze during CMS and state inspections, most recent first.
Several residents' MDS assessments were not accurately completed, including failures to document current tobacco use for multiple residents who smoked or used smokeless tobacco, incorrect coding of a resident as receiving tube feeding when only a mechanical soft diet was provided, and failure to indicate a resident's PASRR status for ID/DD despite supporting documentation. Staff interviews and observations confirmed these discrepancies, and the errors were acknowledged by the MDS nurse and DON.
Surveyors found that food items in a kitchen refrigerator were not labeled, dated, or properly sealed, including lunchmeat, cheese, and a container of chili. A dietary aide could not identify when the items were opened or last used, and the Dietary Manager was unable to explain why expired or spoiled foods had not been removed, despite staff having completed required food safety training. Facility policy and FDA Food Code require all refrigerated foods to be labeled, dated, and tightly sealed.
The facility did not coordinate assessments with the PASRR program or refer residents for necessary services, resulting in a failure to meet regulatory requirements.
A resident with cognitive impairment suffered a second-degree burn after spilling hot coffee on himself in the dining room. The facility failed to implement safety measures or assess residents' ability to handle hot liquids, leaving the coffee pot unattended. Staff did not update care plans or conduct a thorough investigation, contributing to the deficiency.
The facility's kitchen failed to meet food safety standards, with issues such as unlabeled food items, improper hair restraints, and unclean equipment. Staff did not follow protocols for cleanliness, leading to potential risks of cross-contamination and foodborne illness.
The facility's arbitration agreement failed to include required elements, specifically prohibiting residents or their representatives from communicating with officials. The Admission Director and Administrator were unaware of these requirements, affecting 35 residents who entered into binding arbitration under the flawed agreement. No policy or procedure was in place to ensure compliance.
The facility failed to ensure accurate MDS assessments for five residents, leading to incorrect coding of medications and discharge status. Plavix and Aspirin were wrongly coded as anticoagulants, a resident was inaccurately recorded as receiving dialysis, and another was incorrectly noted as discharged to the hospital. These errors were identified through interviews and record reviews, highlighting the importance of accurate documentation for resident care and facility billing.
The facility failed to update care plans for three residents, resulting in discrepancies in code status and fall interventions. Two residents' care plans did not reflect their DNR status, and fall interventions were not updated for two residents who experienced multiple falls. Staff interviews revealed communication gaps and a lack of follow-through in updating care plans, despite previous identification of these issues in an internal survey.
The facility failed to meet residents' nutritional needs by using an incorrect scoop size for ground chicken during a lunch meal. A staff member used a #8 scoop instead of the required #12, due to not reviewing the production sheet and choosing a scoop with holes to drain broth. The Dietary Manager and Administrator acknowledged the issue, emphasizing the importance of correct portion sizes as per the facility's portion control policy.
A long-term care facility failed to maintain an effective infection prevention and control program, as observed in the actions of a CNA and an RN. The CNA did not perform hand hygiene before providing care, failed to change gloves, and transported dirty linens without bagging them. The RN used a disinfectant wipe instead of gauze for a blood sugar check and did not prepare a barrier for supplies. These actions were against the facility's policies and acknowledged by the staff as potential infection control issues.
A resident with Huntington's disease and severe cognitive impairment alleged that a CNA sat her down too hard on the toilet, resulting in a red mark on her back. The incident was not documented, and the facility failed to report the allegation to the state within the required two-hour timeframe. The resident provided inconsistent accounts, and the administrator was informed of the incident the following day, acknowledging the delay in reporting.
A resident with Huntington's disease and severe cognitive impairment alleged that a CNA let her sit down too hard on the toilet, causing a red mark on her back. The incident was not reported within the required two-hour timeframe, as the DON believed the mark was due to the resident's spastic movements. The administrator was informed the next day and reported the incident to the state. The resident gave inconsistent accounts of the incident, and the facility's policy on immediate reporting was not followed.
A CNA failed to provide privacy for a resident during dressing, leaving the door open and not pulling the curtain, which compromised the resident's dignity. The resident, staff, and management acknowledged the importance of maintaining privacy, as outlined in the facility's policy.
A resident with multiple health conditions, including dementia and diabetes, experienced a coffee spill resulting in a second-degree burn. Despite medical interventions being ordered, the facility failed to update the resident's care plan to address the risk of injury from hot liquids. Interviews with staff revealed that the MDS nurse was responsible for care plan updates, but the incident was not documented, highlighting ongoing issues with care plan accuracy and consistency.
A resident with a history of heart disease and Alzheimer's was observed not using oxygen despite an active order for continuous oxygen therapy. Staff interviews confirmed the resident no longer required continuous oxygen, but the order was not updated, leading to incorrect documentation. The facility's policies on oxygen therapy and medication management were not followed, resulting in a deficiency.
A facility failed to ensure a resident was seen by a physician within the first 30 days of admission, as required. The resident, with chronic obstructive pulmonary disease and other conditions, was not seen until after the 30-day period. Interviews with staff revealed a lack of communication and monitoring to ensure compliance with physician visit requirements.
A resident with COPD did not receive nasal spray medication according to protocol, as LVN A failed to instruct the resident to blow her nose before administration. This oversight was confirmed by the DON, Pharmacist Consultant, and Administrator, who all acknowledged the importance of following the manufacturer's guidelines and facility policy to ensure medication effectiveness.
A resident with a history of hypertension and heart disease was administered blood pressure medications outside of the ordered parameters on multiple occasions. Despite blood pressure readings being below the specified thresholds, amlodipine and losartan were given, as confirmed by staff interviews and medication records. This failure to follow medication administration protocols posed a risk to the resident's health.
A resident with a seizure disorder did not have their Keppra levels monitored as required, due to a failure in processing and tracking laboratory orders. The resident's care plan required Keppra levels to be drawn every three months, but this was not adhered to, with the last level drawn several months apart. Interviews revealed a lack of communication and documentation regarding order changes, and the absence of a lab tracking system contributed to the oversight.
The facility failed to ensure a dietary staff member maintained a current food handler certificate, as required by policy. The Dietary Manager was responsible for ensuring staff completed their training, but Cook E continued working with an expired certificate. This oversight could potentially risk residents' safety due to foodborne illness and cross-contamination.
A resident with COPD refused Lasix, and the LVN failed to document notifying the physician, as required by facility policy. The DON and Administrator acknowledged the importance of documentation to ensure proper care.
The facility failed to coordinate hospice care and maintain updated documentation for two residents receiving hospice services. One resident's hospice plan of care and medication record were not updated, while another resident's hospice binder lacked essential documents. Interviews revealed confusion and lack of responsibility between hospice and facility staff, leading to potential risks in care coordination.
Inaccurate MDS Assessments for Tobacco Use, Nutrition, and PASRR Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status of five residents. For several residents who used tobacco products, including cigarettes and smokeless tobacco, the MDS assessments did not indicate current tobacco use, despite documentation in care plans, smoking safety screens, and direct observations of tobacco use during the assessment periods. Interviews with the residents confirmed their ongoing tobacco use, and staff, including the RN and MDS nurse, acknowledged that these residents used tobacco daily. However, the MDS assessments for these residents were not coded to reflect this, resulting in inaccurate documentation. In another instance, a resident was incorrectly coded on the MDS as receiving a feeding tube for nutritional support, despite physician orders, care plans, and direct observation confirming that the resident was on a mechanical soft diet and had never had a feeding tube. The MDS nurse admitted to coding this incorrectly, attributing the error to a busy admission day. The DON also acknowledged the error and recognized that it could impact the resident's care. Additionally, a resident with a diagnosis of cerebral palsy and a positive PASRR for intellectual and developmental disabilities (ID/DD) was not coded appropriately on the MDS. The care plan and physician documentation indicated the presence of ID/DD, but the MDS assessment did not reflect this. The MDS nurse admitted to coding the PASRR status incorrectly. Throughout these cases, the facility's policy required accurate and timely completion of the MDS based on direct observation, interviews, and record review, but these requirements were not met for the residents involved.
Failure to Properly Store, Label, and Date Refrigerated Food Items
Penalty
Summary
The facility failed to properly store, label, date, and seal food items in one of the kitchen refrigerators, as observed during a survey. Specific findings included a Ziploc bag of lunchmeat slices, a large Rubbermaid container with a reddish-brown substance, a Rubbermaid container of sliced yellow cheese, and an opened Ziploc bag containing a manufacturer-labeled bag of mozzarella cheese. None of these items were labeled or dated, and some were not properly sealed. The dietary aide present was unable to identify when the items were opened or last used and stated that, without a date, she would discard the food to ensure safety. The dietary aide confirmed receiving orientation training on food handling but was unaware of the specifics regarding these items. The Dietary Manager (DM) acknowledged responsibility for ensuring staff followed facility policy and for checking food storage areas weekly for expired or spoiled foods but could not explain why these items had not been removed. The DM confirmed that all kitchen staff had completed required food preparation and storage training. The facility's policy and the FDA Food Code require all refrigerated foods to be labeled, dated, and tightly sealed, with leftovers used within 48 hours. The Administrator stated that all products should be labeled and dated according to policy and that it was the DM's responsibility to ensure compliance.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Resident Burned by Hot Coffee Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards, resulting in a second-degree burn for one resident. The resident, who was cognitively moderately impaired and required assistance with various activities, spilled hot coffee on his left leg while in the dining room. The incident led to redness and blisters on the resident's foot, which required medical treatment. The facility did not have a care plan in place for the risk of injury from hot liquids for this resident. Interviews and observations revealed that the coffee pot was left unattended in the dining room, allowing residents to serve themselves. Staff members, including the DON and Administrator, were aware of the incident but did not take immediate action to remove the coffee pot or implement safety measures to prevent further accidents. The facility's policy on hot liquids was not followed, as there was no assessment of residents' ability to safely consume hot liquids, nor were care plans updated to reflect necessary interventions. The facility's failure to implement safety measures and assess residents for hot liquid risks placed residents at risk for injury. Despite the occurrence of the burn, the facility did not conduct a thorough investigation or update the resident's care plan to prevent recurrence. The lack of immediate corrective actions and communication among staff contributed to the deficiency.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Key deficiencies included the lack of labeling and dating on food items such as margarine, minced garlic, and vegetable oil. Additionally, the kitchen staff did not wear proper hair restraints, with hairnets not fully covering their heads. The microwave was found to be dirty with food debris, and the trash can used for food waste lacked a lid, which are both essential for maintaining hygiene and preventing contamination. Further observations revealed that the outside of the ice machine and the iced tea maker cart were not clean, with brown and white substances present. The condiment cart also had a dark/light substance, and the plate domes were stacked with water pooled between them, indicating improper drying practices. A staff member, identified as [NAME] D, was noted to have unclean nails with a black substance while preparing food without gloves, which poses a risk of cross-contamination. Interviews with the dietary staff and management confirmed these practices were against the facility's policies and food safety standards. The Dietary Manager and Administrator acknowledged the importance of cleanliness and the potential risk of foodborne illness due to these failures. The facility's policies on food storage, safe food handling, and sanitation were not followed, as evidenced by the observations and staff interviews.
Deficient Arbitration Agreement Lacks Required Communication Rights
Penalty
Summary
The facility failed to ensure that its arbitration agreement contained all the required elements, specifically regarding the rights of residents or their representatives to communicate with federal, state, or local officials. The arbitration agreement, revised in June 2021, included language that prohibited or discouraged such communication, which is a violation of regulatory requirements. This oversight was identified during a record review and interviews with facility staff. The Admission Director, responsible for admission agreements, was unaware of the specific requirements for arbitration agreements and acknowledged that 35 residents had entered into binding arbitration under the flawed agreement. The Administrator also admitted to being unaware of the need to address communication rights with officials in the agreement, indicating that corporate oversight was relied upon for compliance. There was no existing policy or procedure regarding arbitration agreements, which contributed to the deficiency.
Inaccurate MDS Assessments and Coding Errors
Penalty
Summary
The facility failed to ensure accurate assessments for five residents, leading to incorrect coding on the Minimum Data Set (MDS) assessments. For three residents, Plavix, an antiplatelet medication, was incorrectly coded as an anticoagulant. Additionally, one of these residents also had Aspirin incorrectly coded under the same category. These errors were identified during interviews and record reviews, where it was noted that the MDS Coordinator had misunderstood the classification of these medications according to the Resident Assessment Instrument (RAI) manual. Another resident was inaccurately coded as having received dialysis on their MDS assessment, despite no orders or care plan indicating such treatment. This discrepancy was confirmed through interviews with the resident, who stated they had never been on dialysis. The lack of accurate documentation and coding could potentially mislead care planning and service delivery for the resident. Furthermore, a resident was incorrectly coded as being discharged to the hospital instead of home. This error was discovered through a review of progress notes, which indicated the resident was discharged home with a family member. The MDS Coordinator acknowledged the importance of accurate MDS coding, as it directly impacts the resident's care plan and the facility's billing processes.
Failure to Update Care Plans for Code Status and Fall Interventions
Penalty
Summary
The facility failed to review and revise the person-centered care plans to reflect the current conditions of three residents. Specifically, the care plans for two residents were not updated to reflect their Do Not Resuscitate (DNR) status, despite having physician orders indicating this change. This oversight could lead to inappropriate interventions, such as resuscitating a resident who has opted for DNR, thereby not honoring their end-of-life wishes. Additionally, the facility did not update the care plans for fall interventions for two residents who experienced multiple falls. The care plans lacked new interventions following these incidents, which could result in staff being unaware of necessary measures to prevent further falls. The MDS nurse, responsible for updating care plans, acknowledged the failure to update these critical aspects, despite being aware of the residents' falls and changes in code status. Interviews with various staff members, including the MDS nurse, social worker, and administrative personnel, revealed a lack of communication and follow-through in updating care plans. The facility's internal survey had previously identified inconsistencies in care plan updates, and the MDS nurse was placed on a Performance Improvement Plan (PIP) to address these issues. However, the deficiencies persisted, indicating a systemic problem in ensuring care plans accurately reflect residents' current needs and conditions.
Incorrect Scoop Size Used for Meal Preparation
Penalty
Summary
The facility failed to ensure that meals served met the nutritional needs of residents, specifically during a lunch meal where the incorrect scoop size was used for ground chicken. The production sheet indicated that a #12 scoop size should have been used, but during observation, it was noted that a #8 scoop size was used instead. This discrepancy was due to the dietary staff member not reviewing the production sheet prior to meal preparation and choosing a scoop with holes to drain broth, which was not the correct size. This failure was acknowledged by the staff member, who admitted that it could potentially put residents at risk for malnutrition or weight changes. The Dietary Manager confirmed that it was her responsibility, along with the cook, to ensure correct portion sizes were served. She admitted to noticing issues with staff not using the correct scoop sizes and had verbally trained and in-serviced staff on the importance of using the correct utensils. The Administrator also emphasized the importance of using the correct scoop size to ensure residents receive the correct amount of food. The facility's policy on portion control, approved in 2018, mandates the use of standard portion control procedures and utensils to ensure adequate portions are served to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. One of the deficiencies involved a certified nursing assistant (CNA) who did not perform hand hygiene before providing incontinent care to a resident. The CNA also failed to change gloves when transitioning from handling a dirty brief to applying a clean one. Additionally, the CNA transported dirty linens without bagging them, which is against the facility's infection control policy. These actions were acknowledged by the CNA, who admitted to not following proper procedures and recognized the potential infection control issues. Another deficiency was observed with a registered nurse (RN) who did not use a 2x2 gauze to wipe a resident's finger after checking blood sugar, instead using a disinfectant wipe. The RN also failed to prepare a barrier for her supplies and improperly disposed of the disinfectant wipe on the resident's bed. The RN admitted to these oversights and acknowledged that they could lead to infection control issues. The facility's policies clearly outline the correct procedures for hand hygiene, perineal care, and blood glucose monitoring, which were not followed in these instances. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed that the staff did not adhere to the expected infection control practices. The ADON, who is also the Infection Control Preventionist, and the DON both emphasized the importance of following proper procedures to prevent the spread of infections. The Administrator reiterated the expectations for staff to perform hand hygiene, bag soiled linens, and use appropriate materials for blood glucose monitoring, highlighting the responsibility of the staff to adhere to these protocols.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of a resident with Huntington's disease, anxiety disorder, and dementia. The resident alleged that a CNA sat her down too hard on the toilet, causing a red mark on her back. The incident was not documented in the progress notes, and the facility did not report the allegation to the state within the required two-hour timeframe. The resident, who had severe cognitive impairment, provided inconsistent accounts of the incident, complicating the investigation. Interviews revealed that the CNA responded to an emergency call light and found the resident on the commode. The resident began yelling when the CNA attempted to assist her, prompting a nurse to intervene. The nurse observed a red mark on the resident's back and reported the incident to the DON, who delayed reporting it to the administrator. The administrator acknowledged the requirement to report abuse allegations within two hours but was informed of the incident the following day. The facility's failure to adhere to its abuse reporting policy could place residents at risk of harm.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident with Huntington's disease, anxiety disorder, and dementia, within the required two-hour timeframe. The resident, who had severe cognitive impairment, alleged that a CNA had let her sit down too hard on the toilet, resulting in a red mark on her back. The incident was not documented in the progress notes, and the Director of Nursing (DON) was informed of the incident after 9:00 p.m., but did not report it immediately to the administrator, believing the resident's spastic movements due to her condition might have caused the mark. The administrator was informed of the incident the following day and reported it to the state as soon as she was made aware. During the investigation, it was noted that the resident gave inconsistent accounts of the incident, including naming different individuals as the person who hurt her. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed, leading to a deficiency in timely reporting of suspected abuse.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to protect and promote the rights of a resident by not ensuring privacy during personal care. On the specified date, a CNA assisted a resident with dressing without closing the door or pulling the privacy curtain, leaving the resident exposed to potential view by others, including the roommate who was awake in the room. The CNA acknowledged forgetting to provide privacy and recognized the importance of doing so to ensure the resident's comfort and dignity. Interviews with the resident, ADON, DON, and Administrator confirmed the expectation that privacy should be maintained during care. The resident expressed discomfort at the thought of being seen by strangers while being dressed. The ADON, DON, and Administrator all stated that it was the responsibility of the staff to ensure privacy, and failure to do so was a dignity and privacy issue. The facility's policy on dignity and resident rights emphasized the importance of maintaining privacy by closing doors or using curtains as appropriate.
Failure to Update Care Plan After Resident Burn Incident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a coffee spill resulting in a second-degree burn. The resident, an elderly male with diagnoses including syncope, venous insufficiency, diabetes, and dementia, was cognitively intact and required assistance with various activities of daily living. Despite the incident being documented and medical interventions being ordered, such as monitoring for new symptoms and applying Silvadene cream, the care plan did not include measures to address the risk of injury from hot liquids. Interviews with facility staff, including the MDS nurse, ADON, DON, and Administrator, revealed that the MDS nurse was responsible for updating care plans during morning meetings. However, the coffee spill incident was not added to the resident's care plan, which was acknowledged as an oversight. The facility had previously identified issues with care plan accuracy and consistency during an internal survey, and the MDS nurse was placed on a performance improvement plan, but the deficiency persisted.
Failure to Update Oxygen Order for Resident
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident, leading to a deficiency in care. The resident, a female with a history of hypertensive heart disease, heart failure, essential hypertension, Alzheimer's disease, and cerebellar stroke syndrome, was observed not using oxygen despite having an order for continuous oxygen therapy. The resident's care plan indicated a resolved date for her shortness of breath, yet the order for continuous oxygen remained active. Observations and interviews revealed that the resident was not using oxygen and did not appear to be in respiratory distress. A CNA and an LVN confirmed that the resident did not require continuous oxygen and that the order should have been updated to reflect her current needs. The LVN acknowledged that it was the nurse's responsibility to ensure the accuracy of the resident's orders, and the DON emphasized the importance of following physician orders to prevent potential harm. The facility's policies on oxygen therapy and medication management were not adhered to, as evidenced by the failure to update the resident's oxygen order and the incorrect documentation on the medication administration record. The administrator and DON both recognized the oversight and the potential risk to the resident if she had needed oxygen and was not receiving it. The deficiency highlights a lapse in the facility's process for ensuring accurate and up-to-date medical orders for residents.
Failure to Ensure Timely Physician Visits for New Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 30 days for the first 90 days after admission. Specifically, Resident #245, a female with chronic obstructive pulmonary disease, neurocognitive disorder with Lewy bodies, and an aneurysm of the ascending aorta, was not seen by a physician within the first 30 days of her admission. The resident was admitted on a date not specified in the report, and the physician's progress notes indicated that she was seen on July 16, 2024, which was beyond the required timeframe. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator, and Medical Director, revealed a lack of communication and monitoring to ensure compliance with the physician visit requirement. The ADON and DON acknowledged the responsibility of the nursing staff to notify the physician of new admissions, while the Medical Director admitted to relying on staff to inform him of residents needing initial visits. The failure to perform the initial visit within the required timeframe was attributed to a breakdown in this process, as noted by the Medical Director.
Failure to Follow Nasal Spray Administration Protocol
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident diagnosed with COPD. The resident, who had a moderately impaired cognition, was prescribed Flunisolide Solution nasal spray to be administered twice daily. However, during an observation, LVN A administered the nasal spray without instructing the resident to blow her nose beforehand, which is contrary to the manufacturer's instructions and the facility's policy. This oversight was acknowledged by LVN A, who admitted to not considering the step as the resident was eating at the time. Interviews with the Director of Nursing (DON), the Pharmacist Consultant, and the Administrator confirmed that the standard procedure was not followed. All parties agreed that it was important for the resident to blow her nose prior to the administration of the nasal spray to ensure the medication's effectiveness. The facility's policy and the manufacturer's guidelines both emphasize the necessity of clearing the nasal passages before administering the spray. Despite regular oversight by the DON and monthly visits by the Pharmacist Consultant, this issue had not been previously identified.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of blood pressure medications. The resident, a female with a history of hypertensive heart disease, heart failure, essential hypertension, Alzheimer's disease, and cerebellar stroke syndrome, was administered amlodipine and losartan outside of the ordered blood pressure parameters on multiple occasions. The medication administration record indicated that these medications were given despite the resident's blood pressure readings being below the specified thresholds. On three separate dates, the resident's blood pressure was recorded below the parameters set for the administration of amlodipine and losartan. Despite this, the medications were administered, as evidenced by check marks on the medication administration record. Interviews with staff, including a medication aide, a registered nurse, the Director of Nursing (DON), and the Administrator, confirmed that the medications should not have been given under these circumstances, as it posed a risk of further lowering the resident's blood pressure. The facility's policy on medication administration and management requires adherence to physician's orders, including the correct patient, drug, dose, time, route, charting, results, and reason. The staff involved acknowledged their responsibility in ensuring medications are administered as ordered and recognized the risk posed to the resident by administering the medications outside the prescribed parameters. The deficiency highlights a failure in following established medication administration protocols, which could lead to adverse health outcomes for the resident.
Failure to Monitor Keppra Levels for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of a resident with a seizure disorder. The resident, a male with cognitive impairment and a history of seizures, was prescribed Levetiracetam (Keppra) to manage his condition. The comprehensive care plan required that the Keppra levels be monitored and reported to the medical doctor. However, the facility did not adhere to the order for Keppra levels to be drawn every three months, as the last level was drawn on 07/22/2024, with the previous one on 12/17/2023. Interviews revealed that the nurses were responsible for entering new orders into the computer system, but a change in the order to draw Keppra levels every six months was not properly communicated or documented. The Assistant Director of Nursing (ADON) acknowledged the importance of drawing labs to ensure medication was at a therapeutic level. The Director of Nursing (DON) admitted there was no lab tracking system in place, and the nurses were responsible for processing orders. The Administrator confirmed that nurses were responsible for ensuring laboratory levels were drawn to prescribe the appropriate medication amount.
Expired Food Handler Certificate in Dietary Staff
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, specifically for one out of seven dietary staff members. The deficiency was identified when it was discovered that Cook E's food handler certificate had expired, and the facility did not ensure that it was renewed. The Dietary Manager, who was responsible for ensuring staff completed their food handler certificate training upon hire and every two years, was unsure why Cook E had not completed the necessary training. Despite the expiration of the certificate, Cook E continued to work her assigned schedule. Interviews with the Dietary Manager and the Administrator revealed that the facility relied on staff to ensure their trainings were up to date, which led to the oversight. The Administrator expected the Dietary Manager to ensure that dietary staff had their food handler certificates within 30 days of hire and before they expired. The facility's policy required all personnel involved in food preparation, handling, or serving to obtain a food handler certification from a Texas Department of State Health Services approved provider, valid for two years. The failure to maintain current certification could potentially put residents at risk for foodborne illness and cross-contamination.
Incomplete Documentation of Medication Refusal
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident who refused medication. Specifically, a Licensed Vocational Nurse (LVN) did not document the notification of a physician when a resident refused to take Lasix, a medication used to treat swelling. The resident, a male with a diagnosis of COPD, had a care plan that included interventions for medication refusal, such as educating the resident on potential complications and re-offering the medication. Despite these interventions, the LVN did not document the notification of the Nurse Practitioner about the refusal, which was confirmed during interviews with the LVN and the Nurse Practitioner. The Director of Nursing (DON) and the Administrator acknowledged the importance of documenting such refusals to ensure the care team is informed and can provide appropriate care. The facility's policy requires that any withheld medication be documented, and the attending physician notified. However, the LVN failed to adhere to this policy, which could potentially put the resident at risk for complications related to his COPD. The DON stated that daily reviews are conducted to monitor documentation, but no issues had been noticed previously.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for two residents, who were at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Specifically, the facility did not obtain the most recent updated hospice plan of care and hospice medication record for one resident, and failed to maintain another resident's hospice binder containing essential information related to hospice services. For Resident #10, the facility did not have the most recent hospice plan of care or medication record in the resident's electronic medical record or hospice binder. The hospice documents were expected to be hand-delivered monthly by the hospice company, but there was a lack of clarity and responsibility regarding who was to ensure these documents were updated and available at the facility. Interviews with hospice staff revealed that there was confusion about the process, and the facility's medical records staff confirmed that the last update received was outdated. Similarly, for Resident #6, the hospice binder was missing critical documents such as the physician certification, care plan, medication list, and hospice election form. Hospice staff indicated that updates were supposed to be delivered during visits or meetings, but the facility's staff reported never receiving the necessary paperwork. The facility's administration acknowledged that it was ultimately their responsibility to ensure hospice documents were up to date, and the lack of updated documents could lead to medication errors.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
