Paradigm At Stevens
Inspection history, citations, penalties and survey trends for this long-term care facility in Yoakum, Texas.
- Location
- 204 Walter St, Yoakum, Texas 77995
- CMS Provider Number
- 455544
- Inspections on file
- 37
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Paradigm At Stevens during CMS and state inspections, most recent first.
A resident with multiple medical conditions reported missing funds from her bank account, which were later found to have been used by a former employee for personal purchases after employment ended. Although the misappropriation was confirmed through investigation, the incident was not reported to law enforcement or the State Agency as required by facility policy and regulations. The facility's reporting system showed no record of the incident being reported.
Two residents with mental health diagnoses experienced ongoing discomfort due to elevated room temperatures, despite the air conditioning being set appropriately and the use of multiple fans. The issue was reported to staff but not effectively addressed, and facility leadership was unaware of the ongoing problem until it was identified during a survey.
A resident's personal refrigerator was found to be operating at 75.3°F and contained perishable food items that were not labeled or dated as required. Staff interviews revealed confusion about responsibility for monitoring refrigerator temperatures and food labeling, and the required temperature log was missing for the month. The facility's policy mandates food labeling, dating, and maintaining refrigerator temperatures at or below 41°F, but these standards were not followed.
The facility failed to follow food safety standards, as a staff member did not change gloves after touching a contaminated surface during meal prep, leading to potential food contamination. Additionally, two pans of cake were left uncovered, and a CNA served a resident bread with bare hands, violating the facility's safe food handling policy.
The facility failed to update care plans for three residents, leading to potential care issues. A resident's care plan did not reflect the use of a bed rail for mobility, another resident's impaired vision and need for optometry care were not documented, and a third resident's care plan omitted a prescribed mood stabilizer. These omissions could impact the residents' care and services.
The facility failed to have a qualified Activities Professional to direct their activities program, affecting all 42 residents. Interviews revealed the absence of a certified Activity Director since April 2024, with only an unqualified activities assistant present. The facility's policy required a qualified director to ensure meaningful, person-centered activities, but this was not met.
A resident with no cognitive impairment experienced blurred vision for over two months without receiving optometry care. The facility was aware of the issue but failed to provide timely care due to a broken wheelchair, which hindered transportation to an external optometrist. The resident's care plan did not reflect her need for optometry care, despite her complaints and staff awareness.
The facility failed to ensure that CNAs demonstrated necessary competencies for safe resident transfers. In one case, two CNAs improperly transferred a resident with hemiplegia using a mechanical lift, failing to widen the base for stability and struggling to maneuver the lift. In another case, a CNA did not hold a swinging spreader bar during a transfer, risking injury to a resident with severe cognitive impairment. These actions did not align with facility policies and training protocols.
The facility failed to remove expired syringes of 0.9% sodium chloride injection from the medication room, as observed by surveyors. Eighteen syringes, expired since February 28, 2025, were found, and the DON acknowledged the oversight, which was against the facility's policy for medication management.
A resident's call light was found on the floor, out of reach, while she was in bed, contrary to her care plan and facility policy. The resident, with a history of multiple health issues, was unable to access the call light, potentially delaying care. Interviews with staff confirmed the oversight, which could increase the risk of falls and injuries.
A facility failed to maintain a clean and homelike environment for a resident by not replacing a heavily soiled mattress. The mattress was stained with urine, covering at least 50% of its surface, and emitted a strong odor. The ADON acknowledged the issue, stating the mattress should be discarded, but it was not reported or addressed by staff. The resident, with severe cognitive impairment, was unaware of the condition until informed. Interviews revealed a lack of attention to the mattress's state, despite facility policies emphasizing cleanliness and dignity.
The facility failed to conduct a criminal background check on a newly hired housekeeper before their employment began, contrary to its policies. The housekeeper started working without a background check, which was only completed a month later. This lapse occurred due to the absence of dedicated HR staff, leading to a potential risk of abuse from inappropriate staff.
Two residents' assessments were inaccurate, leading to deficiencies in their care plans. One resident's MDS did not reflect the use of a bed rail for mobility, while another's MDS inaccurately indicated adequate vision despite complaints of blurred vision. These inaccuracies could result in unmet care needs.
A facility failed to include bowel incontinence in a resident's care plan, despite it being identified in assessments. The resident, with severe cognitive impairment, required bowel incontinent care, but the care plan only addressed bladder incontinence. The MDS nurse mistakenly removed the bowel incontinence care plan, believing the issue was resolved. This oversight was confirmed through interviews and record reviews, highlighting a deficiency in the facility's adherence to care plan policies.
Two residents were at risk due to improper mechanical transfer procedures. CNAs failed to follow safe techniques, such as not widening or locking the lift base and not securing the spreader bar, during transfers. Additionally, a required fall mat was not placed beside a resident's bed, contrary to their care plan. These actions did not align with the facility's safety policies and training.
Two residents in a facility did not receive proper incontinence care, leading to potential infection risks. A male resident with severe cognitive impairment was not cleaned in the suprapubic area, and a female resident with similar impairments did not have her labia area properly cleaned. Both CNAs admitted to forgetting these steps despite having received training. The facility's policy on perineal care was not adhered to, as confirmed by the DON.
Two residents in an LTC facility received inadequate respiratory care. A resident's oxygen concentrator filter was found covered in lint, risking respiratory infection, while another resident's nebulizer mask was improperly stored, increasing infection risk. Staff interviews confirmed these deficiencies, highlighting a failure to follow care plans and facility policies.
A facility failed to assess a resident for bed rail entrapment risk and did not obtain informed consent before installation. The resident, with hemiplegia and dementia, used a bed rail without being informed of risks or providing consent. The facility's policy required a physician's order, assessment, and consent, which were not completed, potentially leading to avoidable accidents.
The facility failed to properly store medications, with a narcotic box not affixed in a refrigerator and Latanoprost eye drops stored at room temperature against label instructions. The DON acknowledged these storage issues, which could lead to drug diversion and reduced medication efficacy.
A facility failed to maintain accurate medical records for a resident, incorrectly documenting Depakote as being for dementia instead of a mood disorder. The error was acknowledged by the ADON, who was responsible for reviewing orders. The resident, with severe cognitive impairment and multiple diagnoses, was not receiving medication for dementia, as confirmed by a psychiatric assessment.
A facility failed to maintain a safe environment for a resident by not repairing a hole in the bathroom door, which was acknowledged by both the resident and maintenance staff. The resident, who is cognitively intact and independent, has a history of Parkinson's disease, increasing the risk of injury due to the damaged door. The facility's policy on maintaining a sanitary environment was not followed.
A facility failed to maintain an effective infection prevention and control program, leading to a scabies outbreak among residents and staff. Two residents with significant medical histories were confirmed positive for scabies and treated with Ivermectin. The DON and Administrator were aware of the outbreak but did not report it to the State Survey Agency in a timely manner. Several staff members were also confirmed positive, with some failing to report symptoms, contributing to the spread of the infection.
A resident with COPD did not receive timely respiratory care, as the facility failed to replace oxygen tubing, humidifier, and nebulizer within the specified timeframe. The resident experienced nosebleeds and soreness due to an empty humidifier, and staff interviews confirmed the oversight, with shifts blaming each other. The facility's policy required weekly changes to prevent infections.
The facility did not ensure full-time RN coverage, as required, with no RN present on specified dates. Interviews and record reviews confirmed the absence of RN A and RN B, leaving non-RNs without necessary supervision and guidance. The Administrator acknowledged the requirement but lacked a policy to ensure compliance.
A facility failed to maintain accurate medical records for a resident on PRN oxygen therapy, as the MARs for April and May did not document the required changes of nebulizer, humidifier, and tubing every seven days. The MDS LVN, new to the role, was unable to update the MDS accurately due to missing documentation, leading to incomplete records.
A resident with a recent AKA and osteomyelitis was discharged without proper home health arrangements or education for IV antibiotics and wound care. The facility failed to provide necessary supplies and relied on the resident's RP to manage care with insufficient guidance, leading to potential medical complications.
The facility failed to develop and implement policies for timely reporting of abuse allegations to the State Survey Agency (HHSC). A resident with a history of false allegations accused an LVN of threatening behavior, leading to police involvement. The facility's DON and Administrator did not report the incident to HHSC within the required 2-hour timeframe, and the facility's abuse policy did not meet state regulations.
The facility failed to report a resident's abuse allegations to the State Survey Agency within the required 2-hour timeframe. The resident, who had a history of false allegations, accused a nurse of threatening behavior. Despite the serious nature of the allegations, the facility did not report the incident promptly, leading to a deficiency.
Failure to Timely Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, were reported immediately or within the required timeframe to the administrator and appropriate authorities. Specifically, an incident involving the misappropriation of a resident's funds by a former employee was not reported to law enforcement or the State Agency as required. The resident, who was cognitively intact and had multiple medical diagnoses including necrotizing fasciitis, diabetes with neuropathy, major depressive disorder, and fibromyalgia, reported missing funds from her bank account. The charge nurse directed the resident to the Business Office Manager and Administrator, who investigated and confirmed that over $300 in purchases were made using the resident's debit card by a former employee after their termination, with items shipped to the ex-employee's home address. Despite confirming the misappropriation, the previous administrator decided not to report the incident, citing the refunded amount and canceled card as reasons. The facility's grievance log and reporting system showed no self-reported incident related to the misappropriation, and the facility's policy required immediate reporting of such incidents. Interviews with the DON and current administrator confirmed that the incident was not reported as required by state and federal regulations, and the facility's own policy. The resident had initially given her debit card to the employee to purchase clothing, but unauthorized charges occurred months after the employee's departure.
Failure to Maintain Comfortable Room Temperature for Two Residents
Penalty
Summary
The facility failed to maintain comfortable temperature levels in a room shared by two residents, both of whom had intact cognition and relevant mental health diagnoses. Despite the air conditioning being set to 72 degrees Fahrenheit, observations showed the room temperature ranged from 75.5 to 80.2 degrees Fahrenheit. Both residents reported discomfort, with one stating she sweated profusely and the other expressing a desire for a cooler environment. The issue had been ongoing since their admission, and although the residents reported the problem to nursing staff, only additional fans were provided, which did not resolve the discomfort. Staff interviews revealed that the hallway and the residents' room frequently became very hot, and the issue had been reported to the ADON in the previous month without resolution. The Maintenance Director was unaware of the specific ongoing issue until the day of the survey, at which point he discovered and repaired a dislodged air conditioning duct. Facility leadership, including the ADON and Administrator, were not aware of the residents' ongoing discomfort prior to the survey. The facility's policy required maintaining proper temperature and ventilation to create a home-like environment, which was not achieved in this instance.
Failure to Maintain Safe Food Storage in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to ensure that food stored in a resident's personal refrigerator was maintained in accordance with professional food service safety standards. During observation, the resident's refrigerator was found to contain several food items, including fruit, open containers of ketchup and mayonnaise, and a partially empty container of lunch meat, all of which felt warm to the touch. The refrigerator temperature was recorded at 75.3 degrees F, and there was no thermometer present. The resident reported that the refrigerator temperature had not been checked recently, and that family members had recently provided groceries. There was no evidence of gastrointestinal illness reported by the resident at the time of the survey. Interviews with staff revealed a lack of clarity regarding responsibility for monitoring and documenting refrigerator temperatures, as well as uncertainty about the facility's policy on labeling and dating food in personal refrigerators. The temperature log for the resident's refrigerator was missing for the relevant month, and the staff member responsible for the log had not performed a check during that period. The facility's policy required all food items to be labeled with the resident's name and date of placement, perishable items to be discarded after three days unless otherwise directed, and refrigerator temperatures to be maintained at or below 41 degrees F. These requirements were not met in this instance.
Food Safety Deficiencies in Meal Preparation and Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and during meal service to a resident. During meal preparation, a staff member, [NAME] H, did not change gloves or wash hands after touching a potentially contaminated surface, specifically a utensil drawer, before continuing to prepare meals. This action led to the potential contamination of food items such as tortillas, lettuce/tomato mix, and cheese, which were then served to residents. The staff member acknowledged the mistake and recognized the risk of transmitting food-borne illnesses due to this oversight. Additionally, two pans of cake were left uncovered on a prep table to cool, which could lead to contamination. Furthermore, a CNA served a resident two slices of bread using bare hands without washing or sanitizing them, which could also result in cross-contamination. These practices were against the facility's policy on safe food handling, which mandates the use of clean, sanitized utensils and no bare hand contact with food.
Care Plan Revisions Not Updated for Residents
Penalty
Summary
The facility failed to ensure that care plans were revised by the interdisciplinary team after each assessment for three residents. Resident #16's care plan did not reflect the use of a 1/4 bed rail for mobility and transfers, despite physician orders and the resident's own admission of using the bed rail for assistance. This oversight could potentially lead to a decline in the resident's physical mobility or independence. Resident #35's care plan did not indicate her impaired vision or the need for optometry care, even though she had complained about blurred vision and had been waiting for optometry services for several months. The lack of documentation in her care plan could result in her not receiving necessary care and services. Resident #19's care plan failed to include the administration of Depakote Sprinkles Delayed Release, a mood stabilizer prescribed for her bipolar disorder. The omission of this medication from her care plan could affect the accuracy of her treatment and care. The MDS Coordinator acknowledged these deficiencies, noting the importance of updating care plans to ensure residents receive appropriate care and services. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan for each resident, which was not adhered to in these cases.
Lack of Qualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that their activities program was directed by a qualified professional, affecting all 42 residents. The facility lacked a qualified Activities Professional, which could result in residents not receiving individualized activities tailored to their skills, abilities, and interests. The facility's contract binder confirmed the absence of a qualified Activity Director. Interviews with the MDS Coordinator and the Administrator revealed that the facility had not had a certified Activity Director since April 2024 and December 2024, respectively. Both acknowledged the presence of an activities assistant who was not qualified to lead specialized activities. The facility's policy, revised in June 2019, required a qualified Activity Director to oversee the program, ensuring activities were meaningful and person-centered, adaptable for residents with limitations, and scheduled at various times to meet diverse needs.
Failure to Provide Timely Optometry Care Due to Transportation Issues
Penalty
Summary
The facility failed to ensure that a resident received necessary optometry care, resulting in a deficiency. The resident, who had a BIMS score indicating no cognitive impairment, reported experiencing blurred vision since before Thanksgiving 2024. Despite the resident's complaints and the facility's awareness of the issue, the resident did not receive optometry care for over two months. The facility had been attempting to secure in-house optometry services but had not yet succeeded, and in the meantime, residents were supposed to be sent out for such services. The delay in care was exacerbated by a broken wheelchair, which was the only one suitable for the resident's weight, preventing transportation to an external optometrist. The facility staff, including the MDS Coordinator and the DON, were aware of the situation but did not take sufficient action to resolve the transportation issue, such as checking with a nearby sister facility for a suitable wheelchair. The resident's care plan did not reflect any need for optometry care, despite the resident's complaints and the staff's awareness of her vision issues.
Inadequate Competency in Resident Transfers
Penalty
Summary
The facility failed to ensure that licensed staff demonstrated the necessary competencies and skill sets for safe resident transfers, as evidenced by incidents involving three CNAs. In one instance, CNA C and CNA K improperly transferred a resident with hemiplegia using a mechanical lift. They did not widen the base of the lift for stability, failed to lock the lift when stationary, and struggled to maneuver the lift, causing the resident to rock side to side. Additionally, the resident's feet became stuck under the actuator, and CNA K had to pull them free, which could have led to injury. Both CNAs admitted to not following their training protocols during the transfer. In another incident, CNA D and CNA E transferred a resident with severe cognitive impairment and multiple physical disabilities using a mechanical lift. During the transfer, CNA E failed to hold the spreader bar, which was swinging over the resident's head, potentially risking injury. Although CNA E had received training and passed a skill check-off evaluation, she admitted to forgetting to hold the bar due to nervousness. The DON confirmed that CNA E should have held the spreader bar to prevent it from hitting the resident's head. The facility's policy on transfers and lifts emphasizes safety and minimizing injury risk, but the actions of the CNAs did not align with these guidelines. The mechanical lift's owner's manual also specifies that the base should be widened for stability and locked when stationary, which was not adhered to in these incidents. These failures in following proper procedures during resident transfers could place residents at risk for avoidable falls and injuries.
Expired Syringes Found in Medication Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medications from the medication room. During an observation, surveyors found eighteen syringes of 0.9% sodium chloride injection for flush, each containing 10 milliliters, that had expired on February 28, 2025, inside the 3-side medication room. This oversight was acknowledged by the Director of Nursing (DON) during an interview, who admitted that the expired syringes should have been discarded according to the facility's policy. The facility's policy, titled Consultant Pharmacist Services Provider Requirements, mandates the checking of medication storage areas and medication carts for proper storage, labeling, cleaning, and removal of expired medications. Despite this policy, the expired syringes remained in the medication room, posing a risk of inaccurate drug administration and potentially ineffective therapeutic outcomes. The facility did not have any residents requiring intravenous therapy that would necessitate the use of these normal saline syringes for flush.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while she was positioned on her bed, which is a violation of the resident's right to reasonable accommodation of needs and preferences. The resident, a female with a history of traumatic subdural hemorrhage, dysphagia, hypertension, extrapyramidal and movement disorder, difficulty in walking, and muscle wasting and atrophy, was observed lying on her bed with the call light on the floor beside her roommate's bed, out of her reach. This was contrary to her comprehensive care plan, which specified that the call light should be within reach and answered in a timely manner. Interviews with the resident, an LVN, and the DON confirmed that the call light was not within reach, which could delay care and services. The resident expressed that she was unable to reach the call light and did not know why it was placed on the floor. The LVN and DON acknowledged that the call light should have been accessible at all times, as per the facility's policy revised in December 2023. This oversight could potentially place residents at risk for delays in care and increased risk of falls and injuries.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, specifically by not replacing a heavily soiled mattress. The mattress, used by a resident with severe cognitive impairment and multiple health conditions, was observed to be covered with urine stains over at least 50% of its surface, emitting a strong odor of urine. The Assistant Director of Nursing (ADON) acknowledged the mattress's condition, stating it should be discarded due to its severe staining and odor, which could not be adequately cleaned for continued use. Despite the facility's policy requiring staff to maintain a clean and dignified environment, the issue was not reported or addressed by the staff, and the resident was unaware of the mattress's condition until it was brought to her attention. Interviews with the resident and a Certified Nursing Assistant (CNA) revealed that the resident did not spend much time in her room and was unaware of the mattress's condition. The CNA, who often worked with the resident, admitted to not paying attention to the mattress's state and expressed uncertainty about its cleanliness. The facility's policies on dignity and environmental cleaning emphasize the importance of maintaining a clean and orderly environment, yet these were not adhered to in this instance, leading to the deficiency.
Failure to Conduct Timely Criminal Background Check
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit and prevent abuse, neglect, and misappropriation by not conducting a criminal background check on a newly hired staff member, housekeeper-F, before their employment began. Housekeeper-F was hired and started working at the facility on February 5, 2025, but their criminal background was not checked until March 6, 2025. This oversight occurred because the facility did not have dedicated human resources staff, and the associated facility's staff, who occasionally handled these checks, missed conducting the background check before the hiring date. The facility's policy requires prospective employees to authorize the facility to obtain investigative and/or consumer reports, including criminal history, for pre- and post-employment evaluation. However, this policy was not followed in the case of housekeeper-F, as their background check was delayed until after they had already started working. Although housekeeper-F's criminal background was clear when eventually checked, the failure to conduct this check prior to employment could potentially place residents at risk of abuse from inappropriate staff.
Inaccurate Resident Assessments Lead to Deficient Care Plans
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. Resident #16's quarterly Minimum Data Set (MDS) did not reflect the use of a 1/4 bed rail for mobility and transfers, despite physician orders and the resident's own admission of using the rail for assistance. The MDS Coordinator acknowledged the oversight, noting that the inaccuracy could result in the care plan not reflecting necessary assistive devices, potentially affecting the resident's physical mobility and independence. Similarly, Resident #35's quarterly MDS inaccurately indicated she had adequate vision, despite her complaints of blurred vision and a pending optometrist appointment. The facility Ombudsman and the resident herself confirmed the vision issues, which were not documented in the care plan due to the MDS inaccuracy. The MDS Coordinator admitted that the failure to accurately assess the resident's vision could lead to a lack of necessary vision services. The facility's policy requires a registered nurse to conduct or coordinate each assessment with the interdisciplinary team, ensuring comprehensive and accurate evaluations.
Failure to Address Bowel Incontinence in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental needs. Specifically, the care plan did not address the resident's bowel incontinence, despite it being identified in the comprehensive assessment. The resident, who had severe cognitive impairment and was always bowel incontinent, did not have a care plan reflecting this condition, which could lead to inadequate care. The MDS nurse acknowledged the oversight, stating that the care plan for bowel incontinence was mistakenly removed, believing the issue was resolved when it was not. This error was confirmed through interviews and record reviews, which showed that the resident continued to require bowel incontinent care. The facility's policy required that care plans be reviewed and revised after each assessment, but this was not adhered to, resulting in a deficient practice that could risk the resident not receiving proper care.
Deficiencies in Mechanical Transfer Procedures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision during mechanical transfers for two residents. In the first instance, two CNAs did not follow safe transfer techniques when moving a resident with hemiplegia from the bed to a wheelchair using a mechanical lift. The CNAs did not widen or lock the base of the lift, causing instability, and one CNA pulled on the resident's feet when they became stuck under the actuator. Additionally, a fall mat, which was part of the resident's care plan to prevent injury from falls, was not placed beside the bed as required. In the second instance, during the transfer of another resident with severe cognitive impairment and multiple physical disabilities, a CNA failed to hold the spreader bar of the mechanical lift, allowing it to swing dangerously close to the resident's head. This oversight occurred despite the CNA having received training on the proper use of the lift. The resident's care plan required total assistance with transfers, including the use of a mechanical lift, due to the resident's significant mobility and cognitive challenges. Interviews with the DON and DOR confirmed that the staff did not adhere to the facility's policies and training regarding mechanical lifts. The facility's policy emphasized the importance of maintaining the lift's base in a wide position for stability and ensuring the resident's safety during transfers. The failure to follow these procedures placed the residents at risk of injury during the transfers.
Inadequate Incontinence Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for two residents, leading to potential risks of cross-contamination and urinary tract infections. Resident #11, a male with severe cognitive impairment and multiple health issues, including diabetes and reduced mobility, did not receive proper cleaning of the suprapubic area during incontinence care. The CNA responsible for his care admitted to forgetting to clean the area due to nervousness, despite having received peri-care training the previous year. The resident's care plan required cleaning of the perineal area with each incontinence episode and monitoring for signs of urinary tract infections. Similarly, Resident #143, a female with severe cognitive impairment and frequent bladder incontinence, did not receive adequate cleaning of the labia area during incontinence care. The CNA providing care also admitted to forgetting to separate and clean the labia area due to nervousness, despite having received training. The facility's policy on perineal care, which emphasizes maintaining privacy, reducing infection risk, and promoting skin integrity, was not followed. The Director of Nursing confirmed the lapses in care and acknowledged the need for proper cleaning to prevent infections.
Deficient Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents requiring oxygen therapy, leading to deficiencies in their care. Resident #16, who has a history of hemiplegia, hemiparesis, and chronic obstructive pulmonary disease, was observed receiving oxygen therapy via a nasal cannula. However, the oxygen concentrator filter was found to be covered with white residue and lint, which could potentially lead to an upper respiratory infection. Interviews with the LVN and DON confirmed that the filter was not maintained according to the facility's policy, which requires regular cleaning to prevent contamination. Resident #13, a female resident with a history of sepsis, acute respiratory failure, pneumonia, type 2 diabetes mellitus, and sleep apnea, was also found to be at risk due to improper respiratory care. Her nebulizer mask was observed on the dresser without being covered in a plastic bag, which is necessary to prevent infection when not in use. The LVN and DON acknowledged that the mask should have been stored properly to avoid potential contamination. These observations and interviews highlight the facility's failure to adhere to professional standards of practice and the residents' comprehensive care plans. The lack of proper maintenance and storage of respiratory equipment could lead to respiratory infections, compromising the health and safety of residents receiving oxygen therapy.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess a resident for the risk of entrapment from bed rails before their installation. Specifically, the nursing staff did not complete a necessary assessment, attempt the use of alternatives, review the risks versus benefits, or obtain informed consent from the resident or their representative. This deficiency was identified for one resident who was reviewed for bed rail use. The resident, who had a history of hemiplegia and dementia, was observed using a bed rail without having been informed of the associated risks or having provided consent. The facility's policy required a physician's order, a completed assessment, and a signed consent before the use of side rails. However, the resident's assessment did not reflect the use of a bed rail, and there was no documentation of a discussion about the risks and benefits or an attempt to use alternatives. Interviews with the MDS Coordinator and the Director of Nursing confirmed these oversights, highlighting the importance of ensuring that assistive devices are safe and appropriate for residents. The facility's failure to adhere to its policy could potentially lead to avoidable accidents involving residents who use bed rails.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required. In the 4-side medication room, a narcotic box inside a refrigerator was not permanently affixed, which contained 12 capsules of Dronabinol 5 mg for a resident with multiple health issues, including moderate cognitive impairment and respiratory failure. The Director of Nursing (DON) acknowledged that the narcotic box should have been permanently affixed to prevent drug diversion. Additionally, two unopened bottles of Latanoprost 0.005% ophthalmic solution were improperly stored at room temperature in a medication aide cart, despite the label instructions to keep them refrigerated until opened. The DON confirmed that the medications were not stored according to the label instructions and facility policy, which could render them ineffective. The facility's policy requires medications needing refrigeration to be kept at a specific temperature range with a thermometer for monitoring.
Inaccurate Documentation of Medication Order
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, leading to a deficiency in documentation. Specifically, the psychiatric provider prescribed Depakote for a mood disorder, but the facility incorrectly documented the medication as being for dementia. This error was found in the physician's order and the medication administration record, which both inaccurately stated that the Depakote was for dementia. The Assistant Director of Nursing (ADON) acknowledged that the order was entered incorrectly by a nurse who received the verbal order from the psychiatric provider. The resident involved was an elderly male with multiple diagnoses, including heart failure, muscle weakness, mood disorder, dementia, type 2 diabetes mellitus, and hypoxemia. The resident's significant change Minimum Data Set (MDS) indicated severe cognitive impairment, requiring assistance with transfers. The psychiatric assessment confirmed that the resident's dementia was not being treated with medications, highlighting the inaccuracy in the facility's records. The ADON was responsible for reviewing and auditing all orders but failed to identify the error, which could lead to errors in care and treatment.
Facility Fails to Maintain Safe Environment Due to Damaged Bathroom Door
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public, as evidenced by a hole in the bathroom door of a resident's room. The hole, measuring 20 cm in width and 3 cm in length, was observed in the bathroom door of a female resident who was cognitively intact and independent in her daily activities. The resident, who has a history of Parkinson's disease and other medical conditions, expressed awareness of the hole and a desire for it to be repaired. The maintenance staff acknowledged the presence of the hole and suggested that it might have been caused by the room door hitting the bathroom door. The facility's policy on environmental cleaning emphasizes maintaining a clean and sanitary environment to minimize infection risks, yet this policy was not adhered to in this instance. The failure to address the hole in the bathroom door could potentially lead to injury, particularly given the resident's medical conditions, which include increased tremors and unsteady gait.
Infection Control Deficiency: Scabies Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in an outbreak of scabies among residents and staff. Two residents, both with significant medical histories, were confirmed positive for scabies. Resident #1, a male with diabetes and Alzheimer's disease, was found to have scabies following a skin scraping test. Resident #2, a female with atopic dermatitis and reduced mobility, was also confirmed positive for scabies. Both residents were placed on enhanced barrier precautions and treated with Ivermectin. The Director of Nursing (DON) and the Administrator were aware of the scabies cases among residents and staff but failed to report the outbreak to the State Survey Agency (HHSC) in a timely manner. The DON acknowledged that any infection affecting two or more residents should be considered an outbreak and reported. Despite this, the Administrator initially believed the scabies cases were not a notifiable incident and only recognized the need to report after confirming multiple cases. Interviews with staff revealed that several employees, including CNAs and an LVN, were also confirmed positive for scabies. Some staff members had experienced symptoms but did not report them to the DON or Administrator, contributing to the spread of the infection. The facility's policy required the Administrator or DON to report such incidents, but this was not done promptly, potentially putting other residents, staff, and the community at risk.
Failure to Provide Timely Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required tracheostomy care and tracheal suctioning, as per professional standards of practice. The resident, a 71-year-old male with diagnoses including depression, dementia, COPD, and anemia, was observed receiving oxygen at 2 liters per minute. However, the oxygen tubing, humidifier, and nasal cannula were not replaced within the facility's specified timeframe, which was every Wednesday during the night shift. The humidifier bottle was found empty, and the nebulizer was dated over a month prior, indicating it had not been changed weekly as required. The resident reported experiencing nosebleeds and soreness due to the lack of humidified oxygen and stated that staff shifts were blaming each other for the oversight. Interviews with facility staff, including an LVN and the ADON, confirmed that the humidifier, tubing, and nebulizer should be changed weekly to prevent infections and ensure proper oxygen flow. The LVN admitted to not changing the equipment and acknowledged the charge nurse's responsibility to check and replace the oxygen apparatus. The ADON could not explain why the equipment was not changed as per the facility's procedures and reiterated the importance of changing the equipment every seven days. The facility's Oxygen Therapy policy also emphasized the need to exchange the humidifier when empty and change the tubing if discolored or contaminated.
Failure to Provide Full-Time RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) to serve as the Director of Nursing on a full-time basis, as required. During the month under review, the facility employed two RNs, RN A and RN B, neither of whom clocked hours on the specified dates. This lack of RN presence was confirmed through record reviews and interviews with staff, including RN A, who stated she was not present on the specified dates. The absence of an RN on these days meant that there was no RN available to provide necessary supervision to non-RNs, mentor other nurses, or declare a resident deceased. Interviews with the Assistant Director of Nursing (ADON) and the Administrator revealed that there was no policy or procedure in place for ensuring RN coverage for 8 hours each day. The Administrator acknowledged the requirement for daily RN coverage but could not explain the lack of RN presence on the specified dates. Staff members, including an LVN and a CNA, emphasized the importance of having an RN for guidance and supervision. At the time of the survey exit, the facility had not provided a policy for ensuring 8-hour RN coverage.
Incomplete Medical Records for Oxygen Therapy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was prescribed PRN oxygen therapy. The resident, a 71-year-old male with diagnoses including depression, dementia, COPD, and anemia, was not documented as having their nebulizer, humidifier, and oxygen tubing changed every seven days as per the facility's procedure. This oversight was identified during a review of the resident's Medication Administration Records (MARs) for April and May 2024, which did not capture the necessary procedures for changing the equipment. Interviews with the MDS LVN revealed that the MARs were not accurate for oxygen therapy, as they lacked directives for changing the equipment every seven days. The MDS LVN, who was new to the position, stated that the absence of documentation on the MARs prevented her from updating the MDS accurately. The facility's policy requires direct observation and communication with residents and staff to ensure accurate assessments, but the lack of communication and documentation led to the deficiency in maintaining the resident's medical records.
Inadequate Discharge Planning and Education for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who had undergone a left above-knee amputation (AKA) and was receiving IV antibiotics for osteomyelitis. The resident was discharged without the arrangement of necessary home health services for wound care and IV medication administration. Additionally, the resident's responsible party (RP) was not provided with adequate education on IV antibiotic administration, midline catheter care, or wound care for the surgical incision. The discharge process was inadequately managed, as the facility did not provide the RP with essential supplies for midline catheter and wound care. Interviews revealed that the facility staff assumed the RP had nurse friends who could assist with the resident's care, leading to a lack of formal arrangements for home health services. The RP expressed discomfort with administering the IV medication and reported that the facility only provided verbal instructions, which were insufficient for the resident's complex medical needs. The facility's discharge process was further compromised by a lack of written discharge instructions due to computer downtime. The Director of Nursing (DON) and other staff members acknowledged the abrupt nature of the discharge and the absence of proper documentation and education. The facility's policy on discharge/transfer was not followed, as it required the development of a safe discharge plan and the provision of written instructions, which were not adequately executed in this case.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation, specifically in reporting abuse within 2 hours to the State Survey Agency (HHSC). This deficiency was identified during a review of the facility's policy titled 'Abuse, Neglect, and Exploitation Prevention Policy and Procedure,' which did not include guidelines for reporting to the State Survey Agency/HHSC. The failure to report an allegation of abuse made by a resident until surveyor intervention could place all residents at risk for potential abuse due to unreported allegations of abuse. The incident involved a resident with a history of inappropriate behaviors, including making false allegations. The resident accused an LVN of threatening to shove a back scratcher down his throat and called the local police. The police arrived, interviewed the resident, and found no charges pending. The facility's DON and Administrator were informed of the allegations but did not report them to HHSC within the required 2-hour timeframe. The Administrator initially believed she had 24 hours to report the allegations and was waiting for the final police report before reporting to HHSC. Interviews with the resident, CNA, LVN, DON, and Administrator revealed inconsistencies in the facility's response to the allegations. The Administrator later acknowledged that allegations of abuse should be reported within 2 hours and verified this information online. The facility's abuse policy, last reviewed in December 2023, did not meet state regulations for reporting abuse within 2 hours to HHSC. The Administrator was unaware of this deficiency until surveyor intervention.
Failure to Report Abuse Allegations Timely
Penalty
Summary
The facility failed to report allegations of abuse made by a resident to the State Survey Agency within the required timeframe. The resident, who had a history of inappropriate behaviors and false allegations, accused a nurse of threatening to put a back scratcher down his throat. The resident also claimed that his belongings were being taken and that he was being poisoned. Despite these serious allegations, the facility did not report the incident to the State Survey Agency within the mandated 2-hour window. Interviews with staff and the resident's parole officer revealed that the resident had a pattern of making false allegations and moving between nursing homes. The staff had been instructed to handle the resident with two-person assistance to protect themselves from false accusations. The Director of Nursing (DON) and the Administrator were aware of the resident's behaviors and had documented them as target behaviors in his care plan. However, they did not report the allegations to the State Survey Agency, believing that the resident's history of false allegations and the lack of police action made the report unnecessary. The facility's policy on abuse, neglect, and exploitation required immediate reporting of such allegations to the State Health Department, local law enforcement, and the local ombudsman. However, the policy did not explicitly mention the State Survey Agency. The Administrator initially believed they had 24 hours to report the allegations but later confirmed that the correct timeframe was 2 hours. Despite this, the report was not made within the required period, leading to a deficiency in the facility's handling of abuse allegations.
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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