Park Place Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tyler, Texas.
- Location
- 2450 E Fifth St, Tyler, Texas 75701
- CMS Provider Number
- 676005
- Inspections on file
- 36
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Park Place Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow Enhanced Barrier Precautions (EBP) for three residents who had active EBP orders and clear EBP signage on their doors. CNAs provided bed bath and peri-care without hand hygiene on room entry and without donning gowns, despite posted instructions to use gloves and gowns for high-contact care. An LVN performed enteral feeding for a resident with a PEG tube without wearing a mask or gown, even though PPE was available at the room entrance and EBP signage specified gown and glove use for device care. In interviews, staff admitted they were trained on EBP but either forgot or did not notice they had not donned required PPE, and leadership acknowledged these failures could lead to cross contamination, infection spread, and sepsis.
Three residents with complex medical and psychosocial needs did not have comprehensive, person-centered care plans implemented within the required timeframe, despite multiple care areas being triggered on their assessments. Staff interviews and record reviews confirmed that no individualized care plans were in place, and facility policy requiring such plans was not followed.
A resident with chronic lower leg ulcers did not have wound care accurately documented in the EMR, with multiple days missing sign-offs and some entries made retroactively. Nursing staff could not identify who made certain entries, and the DON was unable to match staff initials in the system, resulting in incomplete records for ordered wound care.
An LVN failed to consistently perform hand hygiene between glove changes while providing wound care to a resident with open areas on both lower extremities. The LVN omitted hand hygiene at several points during the procedure, despite facility policy and standard precautions requiring it after glove removal and before moving from soiled to clean body sites. The DON confirmed that hand hygiene is expected at each glove change.
A resident with cognitive impairment and multiple medical conditions was physically abused by another resident, who grabbed her shirt and bit her hand, resulting in visible injuries and emotional distress. Both residents had no prior behavioral interventions in their care plans, and staff responded after the incident occurred.
Several residents with complex medical and mental health conditions were admitted without timely or complete baseline care plans, as required. In some cases, essential information such as fall risk precautions, dietary instructions, medication orders, therapy services, and social services were missing, and summaries were not provided to residents or their representatives. Staff interviews revealed that sections of the care plans were not completed due to workload and oversight, and the DON acknowledged the lapse in timely completion.
Several residents with risk factors for skin breakdown did not receive required weekly skin assessments due to failures in the facility's EMR system and staff reliance on electronic prompts. Nursing staff missed multiple weeks of assessments, despite care plans and facility policy requiring them, and this was confirmed through record review, staff interviews, and resident observations.
Staff failed to consistently document and reconcile controlled substances during shift changes, resulting in missing signatures and an unaccounted tablet of hydrocodone/acetaminophen for a resident. Multiple medication carts had incomplete narcotic count sheets, and required shift-to-shift counts were not performed as per facility policy.
A resident with multiple medical conditions reported feeling abused after being left on a bedpan for an extended period. Although the allegation was promptly communicated to facility management and the resident later denied abuse during an interview, the facility did not report the initial allegation to the State Survey Agency within the required two-hour timeframe, as mandated by policy.
A resident with multiple diagnoses, including a sacral pressure ulcer and severe cognitive impairment, was not accurately assessed on the MDS because the wound care report was not kept up to date by the former wound care nurse. As a result, the MDS nurse did not document the pressure wound, leading to an incomplete assessment.
A CNA did not perform hand hygiene between glove changes while providing incontinent care to a resident, despite facility policy and personal knowledge of the requirement. The omission was observed during care and confirmed in interviews, with the CNA attributing the lapse to working too quickly. Facility policies reviewed indicated that hand hygiene is required after glove removal and before donning new gloves.
A resident with a history of cardiovascular disease and at risk for skin breakdown developed multiple wounds on the right foot. The facility failed to ensure timely follow-up on a cardiology appointment and a vascular surgery referral, with missed and unrescheduled appointments, lack of documentation, and poor communication among staff. As a result, the resident's wounds deteriorated, leading to gas gangrene and an above-the-knee amputation.
Three residents with significant care needs did not receive timely assistance with ADLs, including incontinent care and bathing. Two residents waited over an hour for staff to respond to call lights for personal hygiene needs, and another received only one documented shower in a month, with staff unable to verify additional care. Facility policies requiring prompt response and regular bathing were not followed, as confirmed by staff interviews and documentation review.
A resident was given the incorrect strength and formulation of a prescribed medication due to unavailability and lack of staff awareness, with the error documented as if the correct medication had been administered. Additionally, expired medications were found on a medication cart, indicating failures in medication storage and removal procedures.
A resident with multiple complex medical conditions, including a tracheostomy, did not have a care plan that addressed tracheostomy or respiratory care needs. The care plan lacked specific interventions, and physician's orders were missing key details such as trach size and necessary equipment. Staff interviews confirmed the omission, and facility policy requiring comprehensive, person-centered care plans was not followed.
A resident with a tracheostomy and complex medical needs did not have required emergency respiratory care equipment, such as a replacement trach, suction catheters, a sterile suctioning kit, or a manual resuscitation bag, at the bedside. Staff interviews and facility policy confirmed these items should have been present for any resident with a trach, regardless of whether it was capped. The resident's care plan and physician orders also lacked necessary details regarding respiratory care.
A CNA failed to properly don PPE, using only one glove and no gown, while assisting a resident with multiple risk factors—including a PICC line, wounds, and an indwelling urinary catheter—during a transfer and catheter care, despite clear EBP signage and available supplies. Staff interviews confirmed knowledge of EBP requirements and the presence of training and visual cues.
A resident with multiple medical conditions, including cognitive deficits and a wound, did not receive timely bathing and hygiene care, resulting in her being found saturated in urine and feces. The CNA responsible was overwhelmed and did not communicate the need for assistance, while the RN acknowledged the responsibility to ensure cleanliness before hospital transport. The DON stated that the facility was not short-staffed, and the CNA and nurses should have ensured the resident received ADL care.
A resident with multiple diagnoses, including type 2 diabetes, was found with an insulin pen on his table, which was not prescribed to him. RN A admitted to leaving the pen, belonging to another resident, on the table by mistake. The DON confirmed that medications should not be left at the bedside or taken into another resident's room, violating the facility's medication administration policy.
A resident with type 2 diabetes was not provided with a physician-ordered Reduced Concentrated Sweets (RCS) diet, as his lunch tray contained regular sugar. The resident's family raised concerns, and staff interviews revealed a lack of awareness and oversight regarding the resident's dietary restrictions. The facility's policy to follow physician's dietary orders was not adhered to, resulting in this deficiency.
The facility failed to maintain an effective infection prevention and control program, as PPE was not readily available for residents requiring Enhanced Barrier Precautions (EBP). Staff, including CNAs and a Corporate Regional RN, did not don necessary PPE when providing care to residents with indwelling catheters, feeding tubes, and wounds. Interviews revealed a lack of adherence to EBP protocols and inconsistent availability of PPE supplies, highlighting deficiencies in the facility's infection control processes.
A resident with multiple health issues was prescribed Sodium chloride 2000 mg every 8 hours, but the facility administered an incorrect dose of 1000 mg every 8 hours due to a transcription error in the EMR. The ADON likely entered the orders incorrectly, and the attending physician was not contacted for clarification. Facility policies on order transcription and confirmation were not followed.
A resident with a history of falls and moderate cognitive impairment fell in the hallway, sustaining facial injuries. The facility failed to notify the family until the next morning, despite policy requirements for immediate notification. The family discovered the injuries during a visit and decided to move the resident to another facility due to the lack of communication.
Failure to Follow Enhanced Barrier Precautions During Direct Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically Enhanced Barrier Precautions (EBP), for three residents who had active physician orders for EBP and visible EBP signage on their doors. Each resident had a documented need for EBP: one resident had a widespread rash and other skin conditions, another had a PEG tube, and a third had other skin changes. Surveyors observed that EBP signage at the room entrances directed staff to clean hands before and after leaving the room and to wear gloves and gowns for high-contact care activities such as dressing, bathing, transferring, changing linens, providing hygiene, changing briefs, assisting with toileting, and device care including feeding tubes. Despite these orders and posted instructions, CNAs and an LVN did not follow EBP requirements during direct care. One CNA entered a resident’s room to perform a bed bath without sanitizing her hands before entry and without donning a gown. Another CNA entered a different resident’s room to provide perineal care and likewise did not sanitize her hands before entering and did not put on a gown. Later, an LVN was observed providing enteral feeding to a resident with a PEG tube without wearing a mask or gown, even though EBP signage and PPE were present at the room entrance. In interviews, the CNAs acknowledged they failed to put on gowns despite having been trained on EBP, and the LVN stated she did not notice she had not put on a gown but was aware of the EBP requirements. The DON, who serves as the Infection Preventionist, and the Administrator acknowledged that staff had been trained and retrained on EBP and stated that such failures could place residents at risk for cross contamination, spread of infection, and sepsis.
Failure to Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to implement comprehensive, person-centered care plans for three residents within the required timeframe. Record reviews showed that for each of these residents, no care plan was implemented within 21 days of admission, despite multiple care areas being triggered by their admission MDS assessments. These care areas included cognitive loss/dementia, ADL function/rehab potential, urinary incontinence/indwelling catheter, psychological well-being, falls, nutritional status, pressure ulcer, pain, and other significant health concerns. The residents affected had complex medical histories, including conditions such as rheumatic mitral stenosis, bipolar disorder, chronic kidney disease, diabetes mellitus type 2, atrial fibrillation, fractured femur, hypertension, and obesity. Their assessments indicated varying levels of cognitive impairment and substantial assistance required for activities of daily living. Despite these needs, the electronic health record reviews confirmed that no individualized care plans were in place for these residents during the survey. Interviews with facility staff, including the MDS Coordinator and the DON, confirmed that the care plans had not been completed as required. The MDS Coordinator was unable to explain why the previous MDS nurse had not completed the care plans, and both staff members acknowledged the importance of care plans in providing individualized care. Facility policy also required the development and implementation of comprehensive care plans to meet each resident's needs, but this was not followed for the residents in question.
Failure to Accurately Document Wound Care and Identify Staff in EMR
Penalty
Summary
The facility failed to ensure that medical records for a resident receiving wound care were accurately documented in accordance with professional standards. Specifically, the Wound Assessment Record (WAR) for one resident did not reflect that wound care to both lower extremities was completed as ordered for multiple days in October. The documentation was incomplete, with several dates missing sign-offs, and there was no way to verify that the care had been provided on those days other than verbal confirmation from nursing staff. Additionally, some entries were made retroactively, and the staff member responsible for certain initials in the electronic medical record (EMR) could not be identified. The resident involved had a history of diabetes, non-pressure chronic ulcers of both lower legs, congestive heart failure, hypertension, and atrial fibrillation. Physician orders required daily wound care, including cleansing, application of Xeroform, ABD pads, and gauze wrapping. The care plan and Minimum Data Set (MDS) confirmed the need for ongoing wound care and indicated the resident was moderately cognitively impaired but able to communicate needs. Despite these requirements, the WAR did not consistently show that wound care was performed as ordered, and staff interviews revealed that documentation was sometimes completed after the fact or not at all. Interviews with the DON and nursing staff confirmed that there was confusion regarding documentation practices, with some nurses documenting in different parts of the EMR or forgetting to sign off on the WAR. The DON was unable to determine the identity of a staff member whose initials appeared in the EMR, and the facility's policy only allowed authorized users with assigned credentials to access and document in the system. The lack of accurate and timely documentation meant that it could not be proven that the resident received the ordered wound care on the specified dates.
Failure to Perform Hand Hygiene Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices during wound care performed by an LVN. During wound care for a resident, the LVN did not consistently perform hand hygiene between glove changes, specifically after removing gloves and before donning new gloves while applying creams and dressings to the resident's lower extremities. The LVN did perform hand hygiene at the start of care and at certain points, but omitted it at several critical steps, contrary to facility policy and standard precautions. Interviews with the LVN revealed uncertainty regarding when hand hygiene should be performed during glove changes, while the DON stated that hand hygiene is expected before care, any time gloves are changed, and when hands are visibly soiled. Review of facility policies confirmed that hand hygiene is required immediately after glove removal and before moving from a soiled to a clean body site. The observed lapses in hand hygiene occurred during wound care for a resident with open areas on both lower extremities, as the LVN alternated between tasks without consistently following hand hygiene protocols.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition and multiple medical conditions, including dementia, diabetes, depression, anxiety disorder, and Parkinson's disease, was not protected from physical abuse by another resident. The incident took place when another resident, who had severely impaired cognition and a history of neurological and behavioral diagnoses, grabbed the first resident's shirt around the neck, stretching the fabric, and bit her hand. The victim sustained a visible bite mark on the back of her left hand and redness to her chest, resulting in pain, anxiety, and emotional distress. The records indicate that both residents had no prior documented behaviors or care plan interventions addressing aggression or risk of resident-to-resident altercations. The incident was witnessed by staff who responded to a disturbance in the facility's entrance/lobby area. Upon arrival, staff found the victim pressing her hand against her chest and standing a few feet away from the aggressor, who was seated in a wheelchair. Immediate assessments revealed the physical injuries described, and the aggressor was subsequently sent to the hospital for evaluation due to his aggressive behavior and a change in baseline condition. Interviews with staff and the residents confirmed that the two individuals had previously sat together in the dining room and that, following the incident, the victim chose to avoid the aggressor. The facility's policy states that all residents have the right to be free from abuse by anyone, including other residents. However, the lack of prior behavioral interventions or monitoring for either resident contributed to the failure to prevent this episode of physical abuse.
Failure to Complete and Provide Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for several residents, as required by policy and CMS guidelines. Specifically, the baseline care plan was not provided to one resident or their representative, and for three other residents, the baseline care plans were either incomplete or not developed within the required timeframe. The documentation review showed missing signatures, incomplete sections, and lack of acknowledgment by residents or their representatives. For one male resident with multiple complex diagnoses, including respiratory failure, depression, PTSD, hypertension, heart failure, COPD, benign prostatic hyperplasia, and obstructive uropathy, there was no indication that the baseline care plan was provided to him or his representative before his death. Another male resident with diagnoses such as type 2 diabetes, sepsis, prostate neoplasm, atrial flutter, anxiety disorder, depression, and hypertension had a baseline care plan that was signed and acknowledged, but the process for other residents was not completed as required. A female resident with mood disorder, schizoaffective disorder, morbid obesity, diabetes, general anxiety, vascular dementia, and depression had a baseline care plan that lacked essential information, including fall risk precautions, dietary instructions, medication orders, therapy services, and a summary provided to her. Another female resident with a femur fracture, delirium, and hypertension had a baseline care plan missing dietary instructions, social services, therapy services, and a summary for her or her representative. Staff interviews confirmed that sections of the baseline care plans were not completed on time due to workload and oversight, and the DON acknowledged the responsibility for timely completion was not met.
Failure to Complete Weekly Skin Assessments for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards of practice to prevent pressure ulcers, as evidenced by the lack of weekly skin assessments for seven residents reviewed for skin assessments. These residents had multiple risk factors for skin breakdown, including impaired mobility, incontinence, diabetes, dementia, and other chronic conditions. Despite care plans indicating the need for regular skin assessments and interventions to prevent pressure injuries, electronic medical records showed that weekly skin assessments were not completed for several consecutive weeks for these residents. Observations and interviews revealed that the facility's new electronic medical record (EMR) system did not consistently generate reminders or assignments for weekly skin assessments if the previous assessment was not completed. Nursing staff, including LVNs and RNs, reported relying on the EMR to prompt them for required assessments, and some were unaware that missed assessments would prevent future reminders. The Director of Nursing (DON) confirmed that the issue with the EMR had led to missed weekly skin assessments and that staff were responsible for completing these assessments unless the resident was under the care of the wound care nurse and physician. Record reviews and direct observations of the affected residents indicated that, at the time of survey, no new pressure ulcers were identified, but some residents had other skin issues such as bruising, healed wounds, or areas of redness. The facility's policy required weekly risk and skin assessments, but these were not consistently performed as documented in the residents' records. Staff interviews further confirmed that the lack of completed assessments could result in residents not receiving necessary care.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to maintain an adequate system for the receipt and disposition of controlled drugs, resulting in the inability to accurately reconcile and account for all controlled substances. Specifically, staff did not consistently sign out or count narcotics during shift changes on multiple medication carts. For one resident, a nurse administered hydrocodone/acetaminophen but did not document the administration on the narcotic count sheet for two consecutive night shifts. This led to a discrepancy in the medication count, with one tablet unaccounted for until it was verbally confirmed by staff that the medication had been given. Observations and interviews revealed that medication aides and nurses did not perform required narcotic counts together during shift changes on several occasions. Staff members reported that if a medication aide was not present, the nurse should count with another nurse, but this protocol was not consistently followed. Review of narcotic count sheets showed numerous missing signatures for both off-going and on-coming shifts across three different medication carts throughout the month, indicating a pattern of noncompliance with established procedures. The facility's policy required that controlled substances be counted at the end of each shift by both the off-going and on-coming staff, with any discrepancies reported to the director of nursing. However, the director of nursing and the administrator were unaware of the extent of missing signatures and incomplete counts until the issue was brought to their attention. The lack of proper documentation and shift-to-shift reconciliation created gaps in the facility's ability to ensure the security and proper administration of controlled medications.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, a male resident with multiple medical conditions, including atrial fibrillation, cardiomyopathy, muscle weakness, and incontinence, reported to a physical therapy assistant (PTA) that he felt abused after being left on a bedpan for an extended period. The resident stated that he was left on the bedpan for approximately 90 minutes and described this as abuse. The PTA documented the grievance and immediately notified the management team and the Administrator. Upon receiving the report, the Director of Nursing (DON) and the Administrator promptly interviewed the resident, who then denied being abused and attributed his frustration to a loss of independence and anxiety about an upcoming discharge. Despite the resident's denial during the interview, the initial allegation of abuse was not reported to the State Survey Agency within the required two-hour window. The Administrator acknowledged that the facility's policy mandates reporting all alleged abuse to the state agency within two hours, regardless of subsequent resident statements. The facility's failure to report the initial allegation of abuse within the mandated timeframe constituted a deficiency. The report and interviews confirmed that the staff were aware of the reporting requirements, and the facility's policy was clear on the need for immediate reporting of all alleged violations involving abuse, neglect, or mistreatment, but the required notification to the state agency did not occur as stipulated.
Inaccurate MDS Assessment Due to Incomplete Wound Documentation
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) admission assessment accurately reflected the status of a resident who had a pressure wound. Specifically, the MDS for this resident did not indicate the presence of a pressure ulcer, despite the resident's medical record and diagnoses confirming its existence. The resident, a male with multiple diagnoses including spinal stenosis, atherosclerotic heart disease, hypertension, spondylosis, dementia, diabetes mellitus, hemiplegia, and a sacral pressure ulcer, was admitted to the facility and had a severely impaired cognition as indicated by a BIMS score of 3. Interviews with facility staff revealed that the MDS nurse relied on the wound care report to complete the MDS, but the former wound care nurse had not kept the wound care report up to date and had failed to include this resident. As a result, the MDS nurse did not document the pressure wound on the MDS. Both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the wound care report was incomplete and that the information should have been included in the MDS assessment, as required by facility policy.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a certified nursing assistant (CNA) not performing hand hygiene between glove changes during incontinent care for a resident. During the observed care, the CNA performed hand hygiene and donned gloves before starting, but after removing gloves following perineal cleaning, did not perform hand hygiene before putting on a new pair of gloves. This process was repeated when the CNA changed gloves again to assist the resident with clean clothing, again omitting hand hygiene between glove changes. Interviews with the CNA confirmed awareness of the requirement to perform hand hygiene between glove changes, but the CNA stated that the step was skipped due to working too quickly. The Director of Nursing (DON) also confirmed the expectation for hand hygiene before and after glove use and after providing care. Review of facility policies on hand hygiene and perineal care further supported that hand hygiene is required after glove removal and before donning new gloves, especially after contact with soiled or contaminated articles and after providing personal care.
Failure to Ensure Timely Specialist Referrals and Follow-Up Leads to Amputation
Penalty
Summary
The facility failed to ensure that a resident received care and services in accordance with professional standards of practice, specifically by not following up on critical medical appointments and referrals. The resident, who had a history of cardiovascular disease and was at risk for skin breakdown, was admitted with orders for a cardiology follow-up and later developed multiple wounds on the right foot. Despite physician orders and wound care recommendations for a vascular surgery referral due to deteriorating arterial wounds and poor blood flow, the facility did not ensure timely scheduling or follow-up of these appointments. Documentation shows that the cardiology appointment was missed and not rescheduled, and the vascular referral was delayed, with staff failing to document missed appointments or notify appropriate personnel. Multiple staff interviews revealed confusion and lack of clarity regarding responsibilities for entering, scheduling, and following up on physician orders and specialist referrals. The charge nurse, treatment nurse, and transportation driver each described breakdowns in communication and process, including a missed vascular appointment due to transportation issues and lack of documentation or rescheduling. The treatment nurse admitted to not following up on the wound doctor's orders and not documenting attempts to schedule the vascular appointment. The Director of Nursing was unaware of the missed appointments until after the resident's condition had significantly deteriorated. As a result of these failures, the resident's wounds worsened over several weeks, eventually developing gas gangrene and requiring an above-the-knee amputation. The resident was transferred to the hospital in an unkempt and malodorous state, with extensive gangrene to the right foot and lower leg. Staff interviews and record reviews confirmed that the lack of timely follow-up and documentation on critical medical appointments directly contributed to the resident's decline and subsequent amputation.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. For one resident with multiple fractures, cognitive deficits, and impaired mobility, observations showed that her call light for assistance remained unanswered for over an hour while she waited for incontinent care. Her care plan indicated she required maximum assistance with bathing and was dependent on staff for all ADLs due to her condition. Another resident, who had diagnoses including muscle weakness and cognitive communication deficit, also experienced significant delays in receiving incontinent care. Observations revealed that her call light was on for over an hour, with multiple staff members entering and exiting the room without providing the needed care. The resident and her family confirmed that staff were slow to respond to call lights. The facility's policy required all staff to respond promptly to call lights, but this was not followed, as confirmed by the DON, who stated that waiting over an hour for care was unacceptable. A third resident, with dementia and anxiety disorder, was found to have received only one shower during the entire month, according to the facility's shower log. Although staff believed this was a documentation issue, they could not provide evidence that more showers were given. The facility's policy required regular bathing services, but documentation did not support that this standard was met for the resident.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the accurate acquisition, receipt, dispensing, and administration of medications for one resident and failed to properly manage medication storage on one medication cart. Specifically, a medication aide administered calcium carbonate 500 mg tablets, crushed, to a resident instead of the prescribed calcium carbonate 750 mg with simethicone 250 mg chewable tablets, as ordered by the physician. The correct medication was not available on the medication cart, and staff were unaware if it was available elsewhere in the facility. The medication administration record was documented as if the correct medication had been given, despite the substitution. Additionally, expired medications, including acetaminophen, melatonin, and ondansetron, were found on the first-floor east hall nurse's medication cart. These expired medications had not been removed in accordance with facility policy, which requires immediate removal and disposal of outdated, contaminated, discontinued, or deteriorated medications. Interviews with staff confirmed that monthly reviews were expected, but expired medications remained accessible on the cart at the time of the survey.
Failure to Develop Comprehensive Care Plan for Tracheostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the tracheostomy care needs of a resident. Record review showed that the resident was admitted with multiple diagnoses, including anemia, dysphagia following cerebral infarction, COPD, GERD, and acute kidney failure, and had undergone surgery on the digestive system. Despite these complex medical needs, the resident's care plan did not include any care area or interventions related to tracheostomy or respiratory care. Additionally, physician's orders did not specify tracheostomy size, replacement cannula, suction machine, manual resuscitation bag, or dietary changes. Interviews with facility staff revealed that the MDS coordinator, who was responsible for initiating and updating care plans, acknowledged that the care plan had been revised but did not address tracheostomy care, and was unsure how this omission occurred. The DON confirmed that the interdisciplinary team is responsible for developing individualized care plans and emphasized the importance of updating care plans to communicate residents' needs and ensure proper care. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question.
Failure to Provide Required Respiratory Care Equipment for Resident with Tracheostomy
Penalty
Summary
A resident with a history of acute respiratory failure, tracheostomy, muscle weakness, dysphagia, and cognitive communication deficit was not provided with necessary respiratory care equipment as required by professional standards and facility policy. Observations revealed that the resident, who had a capped tracheostomy tube, did not have a replacement trach, suction catheters, a sterile suctioning kit, or a manual resuscitation bag at the bedside. The resident's care plan and most recent MDS assessment did not reflect the need for respiratory care, and physician orders lacked specification of trach size. Interviews with the Regional Nurse Consultant and an RN confirmed that essential emergency tracheostomy equipment should be kept at the bedside for any resident with a trach, regardless of whether the trach is capped. Facility policy also required the presence of specific emergency tracheostomy supplies at the bedside. The absence of these items constituted a failure to provide safe and appropriate respiratory care for the resident in accordance with professional standards, the care plan, and physician orders.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident requiring Enhanced Barrier Precautions (EBP). During an observation, a CNA assisted a male resident, who had multiple risk factors including bacteremia, chronic wounds, a PICC line, and an indwelling urinary catheter, to transfer from his wheelchair to his bed and adjusted his urinary catheter drainage bag. The CNA did not don a gown and only wore one glove on her left hand, despite being aware of the resident's need for EBP and the requirement to use both gown and gloves for direct care. PPE supplies were available outside the resident's room, and the room was clearly marked to indicate EBP was required. Interviews with the CNA and facility leadership confirmed that staff had been trained on EBP protocols, and that visual cues and PPE supplies were in place to support compliance. The CNA acknowledged her failure to fully don PPE, attributing it to not expecting the resident to request a transfer at that time and only having one glove available. Facility policy required the use of gown and gloves for high-contact care activities, including transferring and device care, for residents with wounds or indwelling medical devices.
Failure to Provide Timely ADL Care and Hygiene
Penalty
Summary
The facility failed to maintain grooming and personal hygiene for a resident who was dependent on staff for activities of daily living (ADL) care. The resident, who had multiple medical conditions including fractures, sepsis, and cognitive deficits, was not provided timely bathing and hygiene care. During an interview and observation, the resident expressed that she had not received her daily cleaning, which was crucial due to a wound on her coccyx. The resident was found saturated in urine and feces, with a dressing that had not been changed since two days prior. She reported that CNAs often did not return after responding to her call light, leaving her feeling dirty and embarrassed, especially during a recent hospital visit. The CNA responsible for the resident admitted to being overwhelmed with the workload and did not communicate the need for assistance. The RN on duty acknowledged that it was his responsibility to ensure the resident was clean before hospital transport, but the wound care nurse was not available. The Director of Nursing stated that the facility was not short-staffed and that the CNA and nurses should have ensured the resident received ADL care. The wound care nurse confirmed that when working the floor, each nurse was responsible for their treatment and wound care duties. A confidential interviewee corroborated the resident's condition, stating that the resident was dirty and saturated in urine when picked up for hospital transport.
Improper Medication Handling and Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, as evidenced by an incident involving the improper handling of medication. A resident, who had multiple diagnoses including type 2 diabetes mellitus, was found with an insulin pen on his over-the-bed table. The resident was unable to explain how the insulin pen, which was not prescribed to him, ended up on his table. This incident was observed during a visit by the resident's family, who questioned the presence of the insulin pen. An interview with RN A revealed that he was responsible for administering medications and had mistakenly left the insulin pen, which belonged to another resident, on the table while assisting with activities of daily living. The Director of Nursing confirmed that medications should not be left at a resident's bedside and that no resident's medication should be taken into another resident's room. The facility's policy on medication administration emphasizes administering medication as ordered and observing resident consumption, which was not adhered to in this instance.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to ensure that a resident received a therapeutic diet as prescribed by his physician. The resident, an elderly male with multiple diagnoses including type 2 diabetes mellitus, was observed with a lunch tray containing six packs of regular sugar, despite having a physician-ordered Reduced Concentrated Sweets (RCS) diet. The resident's family questioned the presence of sugar on the tray, given his diabetic condition. Interviews with facility staff revealed a lack of awareness and oversight regarding the resident's dietary restrictions. A CNA was unaware of the resident's diet restriction, citing his recent admission as a reason. The Director of Nursing (DON) and a Registered Nurse (RN) acknowledged the oversight, admitting that the dietary staff should have removed the sugar from the tray, as the diet slip clearly indicated an RCS diet. The facility's policy mandates adherence to physician's dietary orders, but this was not followed, leading to the deficiency.
Inadequate Infection Control and PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for three residents. Observations revealed that containers with clean PPE products and containers to discard used PPE were not available in the halls or nearby the rooms of the residents requiring EBP. This deficiency was noted for residents with indwelling catheters, feeding tubes, and wounds, which necessitated the use of gowns and gloves during direct care. During the survey, it was observed that staff members, including CNAs and a Corporate Regional RN, did not don the required PPE when providing care to residents. For instance, CNA A and the Corporate Regional RN assisted a resident without wearing gowns, despite the presence of an orange magnet indicating the need for EBP. Similarly, CNA E failed to don PPE while transferring another resident and handling their urinary catheter drainage bag. Interviews with staff revealed a lack of adherence to EBP protocols, with some staff members acknowledging the absence of PPE supplies as a reason for non-compliance. The facility's policy on Enhanced Barrier Precautions was not effectively implemented, as evidenced by the inconsistent availability of PPE supply boxes and the lack of specific EBP indications in residents' care plans. Interviews with the ADONs and the DON highlighted the absence of a robust process to ensure the presence and supply of PPE on each hall. The facility's failure to integrate a comprehensive infection control process placed residents at risk for the transmission of communicable diseases and infections.
Medication Administration Error Due to Transcription Mistake
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services to meet the needs of a resident, specifically in the administration of Sodium chloride. The resident, a male with multiple diagnoses including intracranial injury, neck fracture, hypoxemia, disorientation, chronic respiratory failure, and hyponatremia, was prescribed Sodium chloride 2000 mg every 8 hours following a hospital visit. However, the facility administered an incorrect dose of 1000 mg every 8 hours over several months, from March to July, and missed a dose entirely on one occasion in July. The error originated from a transcription mistake when entering the hospital discharge orders into the facility's electronic medical records (EMR). The admitting nurse or the Assistant Director of Nursing (ADON) was responsible for entering these orders, but there was a lack of clarity on who actually performed the task. The ADON admitted to likely being the one who entered the orders and acknowledged the oversight. The attending physician expected the orders to be entered as per the hospital's summary and noted that no one contacted him to verify or change the order. The facility's policies required licensed nurses to transcribe physician orders accurately and confirm them with the physician if needed. However, these procedures were not followed, leading to the resident receiving an incorrect medication dosage. Interviews with staff revealed a lack of adherence to the policy, as the nurse did not reach out to the physician for clarification, especially given the discrepancy between oral and G-tube administration instructions.
Failure to Notify Family After Resident Fall
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative after an accident involving the resident, which resulted in injury and had the potential for requiring physician intervention. The incident involved a female resident with a history of myocardial infarction, falls, cerebral infarction, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident, who had moderate cognitive impairment, fell in the hallway and sustained a bruise and an abrasion to her face. The family was not notified until the next morning, despite the facility's policy requiring immediate notification. The incident report indicated that the fall occurred at 5:35 PM, but the family was not informed until 10:25 AM the following day. The resident's nurse assessed the injuries immediately but did not notify the family due to the resident's refusal of care and the nurse's failure to remember the notification requirement. The family discovered the injuries during a visit the next morning and expressed their dissatisfaction with the lack of communication, leading them to decide to move the resident to another facility. Interviews with the facility staff, including the Administrator, RN, LVN, ADON, and DON, revealed that the staff were aware of the requirement to notify the family immediately after such incidents. However, the nurse on duty failed to do so, resulting in a misunderstanding and loss of trust between the family and the facility. The facility's policy on fall management clearly stated the need for immediate family and physician notification, which was not adhered to in this case.
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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