Park Valley Inn Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Rock, Texas.
- Location
- 17751 Park Valley Drive, Round Rock, Texas 78681
- CMS Provider Number
- 676471
- Inspections on file
- 48
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Park Valley Inn Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities was found by a CNA in the early morning with arms tangled between a bed rail and mattress, with new bruising and skin tears to the arms and hands. The CNA reported the incident to the night‑shift LVN, who stated he observed only bruising, applied moisturizer, and contacted the NP, but he did not promptly document the event or clearly identify it as an incident involving potential injury. No timely progress note was entered before shift change, and the day‑shift LVN and unit director later discovered significant bruising without prior documentation from the night shift. A wound assessment later that day documented new non‑pressure skin tears and recorded notifications to the resident, representative, and physician, demonstrating that immediate consultation with the practitioner and notification of the resident’s representative at the time of the initial change in condition did not occur as required.
Two residents with significant medical needs did not receive care in accordance with their care plans or professional standards, as a CNA failed to assist them with toileting and responded unkindly, leaving them without necessary help and making them feel reluctant to ask for assistance.
A resident with a history of behavioral health issues physically assaulted another resident, resulting in a fall and injury. Despite a care plan addressing the potential for aggression, the incident occurred when the aggressive resident became upset about another resident entering her room. Staff responded to the incident, and the injured resident sustained a skin tear. The facility was found noncompliant for not ensuring residents were free from abuse.
A resident admitted with fractures and requiring assistance with eating did not receive the necessary help during a meal, despite the care plan specifying this need. The CNA on duty delivered the meal tray but did not assist, having not checked the care plan or Kardex. The DON confirmed that the care plan should guide staff actions, but in this case, the intervention was not followed.
Several residents with severe cognitive impairment and complex medical needs did not have individualized, measurable care plans, and required interventions such as 1:1 and in-room activities were not consistently implemented or documented. Staff interviews and activity logs confirmed that these deficiencies led to unmet resident needs and a lack of adherence to facility policy.
The facility failed to implement adequate infection control measures, leading to an influenza outbreak among residents. Staff did not test all symptomatic residents or use proper PPE, and there was a lack of communication and adherence to protocols. This resulted in the spread of infection among residents with chronic conditions, increasing their risk of complications.
A resident with multiple health conditions was injured when a mechanical lift, not properly maintained or inspected, failed during a transfer. The lift fell on the resident, causing a lumbar fracture and hemorrhage. Staff interviews revealed inadequate communication and procedures for handling faulty equipment, contributing to the incident.
The facility failed to maintain food safety and hygiene standards in the kitchen. Staff members were observed not wearing proper hair restraints and masks, and one staff member repeatedly failed to perform hand hygiene when changing gloves or handling food. These actions were against the facility's policies and could lead to cross-contamination.
The facility failed to ensure that call lights were within reach for five residents, leading to instances where residents could not call for help. Observations showed call lights on the floor or out of reach, and interviews with staff confirmed that call lights should always be accessible. This deficiency affected residents with varying levels of cognitive and physical impairments, highlighting a pattern of neglect in providing necessary accommodations.
The facility failed to develop and update comprehensive care plans for three residents, including activity preferences and dental status. A resident with Alzheimer's and anxiety had no documented activity preferences or dental status updates, while another resident with dementia and bipolar disorder lacked updated activity preferences. The facility's policy requires timely care plan development, but staff interviews revealed unclear responsibilities, contributing to these deficiencies.
The facility failed to maintain resident dignity and hygiene by not ensuring daily clothing changes for several residents and not addressing a strong urine odor in a resident's room. Despite staff awareness of residents' care needs and refusals, there was a lack of documentation and care planning to address these issues effectively.
A resident with Alzheimer's was improperly restrained in a wheelchair with locked wheels against a desk or table, preventing her from getting out and posing a risk of injury. Facility staff, including a CNA, nurse, DON, and ADM, acknowledged the situation as a restraint but revealed a lack of training and policy on restraint use.
A resident with severe cognitive impairment was slapped by another resident with mild cognitive impairment, highlighting a failure in the facility's abuse and neglect prevention policies. Despite staff training, inconsistencies in reporting and handling such incidents were evident, as the incident was not reported or addressed according to the facility's procedures.
A resident with multiple health conditions experienced significant weight loss due to the facility's failure to maintain her nutritional status. The resident was not consistently weighed, her care plan was not updated, and she did not receive adequate assistance with meals. Staff members were aware of her poor meal intake but failed to take appropriate actions or communicate effectively, leading to a decline in her health condition.
The facility failed to remove discontinued medications and properly reconcile controlled drugs for two residents, leading to medication errors. A resident with Alzheimer's had Klonopin left in the cart despite discontinuation, and another resident had Tramadol discrepancies. Staff interviews revealed a lack of communication and adherence to policies, with the DON unaware of the issues.
A resident with dementia and other conditions experienced an unwitnessed fall in an LTC facility. Despite being found on the floor multiple times and showing signs of pain, the necessary assessments and documentation were not completed by the nursing staff. The resident was not sent to the ER until the following evening, where she was diagnosed with a hip fracture. The lack of documentation and communication among staff delayed the recognition of the resident's condition.
A CNA in an LTC facility threw a cup at a resident during breakfast, leading to a violation of the facility's abuse policy. The resident, with severe cognitive impairment, experienced pain but no lasting injury. Witnesses confirmed the incident, and the CNA admitted to acting out of frustration. The facility's policy emphasizes protecting residents from abuse.
Two residents requiring nebulizer treatments were found with masks and tubing not stored in protective bags, contrary to facility policy. The equipment was exposed, foggy, and dirty, posing a risk for respiratory infections. The DON acknowledged the oversight and the potential risk involved.
A resident with severe cognitive impairment and receiving hospice services was not included in the care planning process at the LTC facility. The facility failed to notify or involve the hospice service provider in interdisciplinary team meetings, despite policies requiring such collaboration. This lack of communication was acknowledged by the facility's administrator.
A facility failed to coordinate hospice care for a resident with severe cognitive impairment, leading to a lack of communication with hospice representatives about the resident's aggressive behaviors and need for transfer. The facility did not notify the hospice service provider of significant changes in the resident's condition or involve them in care planning meetings, contrary to policy requirements.
Failure to Immediately Notify Practitioner and Representative After Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after a change in condition related to new skin injuries. The resident was an elderly male with Parkinsonism, unspecified dementia with severe cognitive impairment (BIMS score 3/15), atherosclerosis, and heart disease, who required staff assistance with ADLs and had a care plan identifying fall risk and use of assist rails and a low bed. On the early morning in question, a CNA reported finding the resident with his forearms or hands tangled between the bed rail and mattress, noting skin tears on both elbows and bruising on the hands and forearms, and stated he immediately reported this to the male charge nurse (LVN B). The CNA documented that the resident was found between the bed rail and mattress and that he put the resident back in bed and reported it to the nurse. LVN B stated that around the same early morning time, the CNA only told him about bruises on the resident’s arms and did not report that the resident had been tangled or had a fall. LVN B reported that he assessed the resident and saw only bruises, applied moisturizer, and contacted the NP, who advised monitoring and did not order x‑rays because there was no reported fall. LVN B’s progress note documenting discolored areas to both arms and notification of the resident’s representative and NP was entered as a late entry approximately eight hours after he was first notified of the incident. The DON later stated that his expectation was that staff immediately report any incidents or changes to the NP and that LVN B did not enter progress notes in a timely manner. Subsequent observations and interviews showed that other staff became aware of the bruising later that morning. The UD learned of the bruises from the day‑shift charge nurse (LVN C), confirmed with the CNA that the resident had been found tangled in the assist rail, and observed unusual bruising on the resident’s hands while he was in the dining room. LVN C reported that when she came on duty and checked the electronic record, there were no night‑shift notes about the bruising, and she observed bruises worse than usual and reported them to administration. A wound assessment completed that afternoon by the treatment nurse documented two new non‑pressure skin tears/abrasions on the right hand and right elbow with an onset date matching the incident date, and notifications to the resident, representative, and physician were recorded at that time. The facility’s incident/accident policy and federal regulation at 42 CFR §483.10(g)(14)(i)(A) require immediate assessment and practitioner and representative notification after an accident involving injury with potential need for physician intervention, which was not done promptly in this case.
Failure to Provide Dignified and Kind Care to Residents
Penalty
Summary
The facility failed to ensure that two residents received care in accordance with professional standards of practice, their person-centered care plans, and their expressed choices. One resident, a woman with a history of cerebral infarction, insomnia, and generalized anxiety disorder, was care planned to require assistance from one staff member for toileting due to fluctuating weakness and fatigue. Despite being cognitively intact, she reported that after activating her call light for bathroom assistance, a CNA responded by questioning why she did not get up herself, then left without providing help. The CNA returned approximately 30 minutes later without speaking or assisting, leaving the resident feeling bad about asking for help. Another resident, a male with hemiplegia and hemiparesis following cerebral infarction, type II diabetes with nephropathy, and end stage renal disease, also required partial to moderate assistance for toileting due to generalized weakness and amputation. He reported that during the night shift, the same CNA turned away and left when he needed to be cleaned up, despite his occasional dizziness and need for restroom assistance. He stated that he reported the incident to the administrator and that the experience made him feel like he was not receiving the care he needed. Interviews with staff confirmed awareness of the CNA's behavior, with one LVN noting gossip about the CNA not treating residents fairly. The administrator confirmed being made aware of the incidents, including a written letter from the female resident describing the unkind treatment. The facility's policy on dignity emphasizes care that promotes residents' well-being, satisfaction, and self-worth, supporting their rights and preferences in daily living activities. The events described represent a failure to provide care in a kind and dignified manner as required by both policy and regulation.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when another resident physically assaulted her. On the date of the incident, a resident with a history of schizoaffective disorder, anxiety, and depression, who was known to have potential for physical aggression, pushed another resident to the ground after becoming angry about the other resident entering her room. The assaulted resident, who had moderate cognitive impairment and multiple medical conditions including diabetes, heart failure, and chronic pain, sustained a skin tear on her left elbow as a result of the fall. The incident was witnessed by staff who responded to a scream and found the injured resident on the floor. Interviews and record reviews revealed that the aggressive resident had a documented care plan addressing her potential for physical aggression, with interventions such as staff intervening before agitation escalates and guiding her away from sources of distress. Despite these interventions, the resident became agitated and physically pushed the other resident, resulting in injury. The injured resident reported the assault to staff and requested that the police be called. Staff and other residents described the aggressive resident as a loner who could become impulsive and aggressive when triggered, while the injured resident was described as calm and helpful. The facility's failure to prevent the assault and injury constituted noncompliance with regulations requiring residents to be free from abuse, neglect, and mistreatment. The incident was reported to the appropriate authorities, and the facility's own investigation confirmed that the aggressive resident had pushed the other resident, causing her to fall and sustain an injury. The deficiency was identified as past noncompliance, with the noncompliance period beginning on the date of the incident and ending a few days later.
Failure to Implement Person-Centered Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes to meet the needs of a resident who required assistance with eating. The resident, an older adult male admitted with fractures to the nasal bone and spine, had an initial care plan indicating a need for one staff member's assistance during meals. However, on one occasion, the resident's dinner tray was left untouched, and he did not receive the required assistance with eating as outlined in his care plan. Interviews revealed that the CNA responsible for the resident's care delivered the meal tray but did not provide feeding assistance, believing the resident could feed himself and not checking the care plan or Kardex for specific instructions. The DON confirmed that the care plan is intended to guide staff in providing appropriate care and that not following it could result in harm. The facility's policy requires a comprehensive care plan for each resident, but in this instance, the intervention for feeding assistance was not implemented.
Failure to Develop and Implement Comprehensive, Measurable Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents, specifically neglecting to include measurable objectives and timeframes to address their medical, nursing, and psychosocial needs. For one resident with severe cognitive impairment and multiple diagnoses, the care plan addressing dehydration risk was incomplete, lacking individualized details and a specific timeframe for the goal. The interventions listed, such as offering additional fluids, were not sufficiently tailored or updated to reflect the resident's current condition. Additionally, the facility did not ensure that care plan interventions for diversional activity deficits, such as 1:1 and in-room activities, were implemented and documented for multiple residents with severe cognitive impairment and various mental health diagnoses. Review of activity logs over several weeks showed that these residents were repeatedly not provided with the required 1:1 or in-room activities as outlined in their care plans. Interviews with staff confirmed that not all residents received these interventions, and documentation was inconsistent or missing for significant periods. Staff interviews revealed a lack of clarity and consistency regarding responsibility for implementing and documenting activities. The activity director and assistant acknowledged gaps in providing and recording 1:1 activities, and the interdisciplinary team members described expectations for care plan updates and monitoring that were not met in practice. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and regular updates, but these standards were not upheld, resulting in unmet resident needs.
Inadequate Infection Control Measures Lead to Influenza Outbreak
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for several residents. Specifically, the facility did not test all residents who exhibited flu-like symptoms and failed to implement quarantine or droplet precautions when indicated. This oversight was observed in multiple residents, including those with acute upper respiratory infections, dementia, and other chronic conditions, who were at risk of respiratory distress and other complications. Observations revealed that staff, including CNAs and LVNs, did not adhere to Enhanced Barrier Precautions, such as donning gowns when required during resident care activities. For instance, a CNA was seen passing out trays without proper PPE, and an LVN administered medication via a gastrostomy tube without wearing a gown. Additionally, there was a lack of proper signage for PPE and airborne precautions outside the rooms of residents suspected of having the flu. Interviews with staff indicated a lack of communication and proper protocol adherence. The RN and CNA mentioned that they did not focus on PPE signage, assuming it was the responsibility of the DON or ADON. The facility's Infection Control Policy and quick reference for isolation precautions were not followed, contributing to the spread of infection among residents. The facility's failure to promptly notify medical providers and implement necessary precautions exacerbated the situation, leading to an outbreak of influenza within the facility.
Removal Plan
- The Director of Nursing and Administrator will be inserviced by the Regional Director of Clinical Services on Influenza Outbreak Management in Long Term Care.
- The Medical Director and patients assigned providers were updated on all patients with flu symptoms and on all patients that were positive by the DON.
- All licensed staff to be inserviced on notifying providers of changes in condition to include a pre/post test by the Regional Director of Clinical Services and/or Director of Nursing Services.
- All staff to be educated on Influenza and Outbreak Management in long term care to include a pre/posttest by the Regional Director of Clinical Services and/or Director of Nursing. Inservice will include signs and symptoms, precautions to take, prevention measures, isolation and outbreak management.
- All licensed staff will be inserviced on Proactive Healthcheck orders by the Regional Director of Clinical Services and/or Director of Nursing. The licensed nurse will enter this order for all patients to capture any flu signs and symptoms. The Proactive Healthcheck will be utilized through the remaining of the flu season.
- The Regional Director of Clinical Services completed a 100% chart audit, identifying all residents with flu symptoms to ensure the providers were notified. All providers were notified by the Director of Nursing Services of all patients with symptoms.
- An audit was conducted by the Regional Director of Clinical Services identifying all patients with active flu and flu symptoms to ensure they were isolated according to the CDC guidelines. All patients verified to have the correct precautions in place.
- Facility is utilizing the PHC Proactive Health Check daily -EHR tool which monitors for abnormal symptoms that may indicate a condition change and other possible illnesses in the residents. The symptoms monitored include-abdominal pain, chills or repeated shaking with chills, diarrhea or other GI upset, headache, loss of smell, loss of taste, muscle pain, nausea, Oxygen saturation, red shadowed eyes or pink eyes, shortness of breath, sore throat, and tingling sensation in face or hands. The PHC dashboard will be reviewed daily during stand up by the DON and/or ED.
- The Director of Nursing Services and/or designee (ADON, UM, ED) will review the 24 hour report (nursing documentation) daily during the clinical stand up meeting with staff monitoring for patient change of conditions and ensuring notification to providers was done. This process will be ongoing.
- The Sr. Regional Director of Clinical Services will review the 24 hour report (nursing documentation) weekly for four weeks to monitor for patient change of conditions and ensure notification to providers was done.
- The DON and/or designee (ADON and/or IP) will perform a minimum audit of 3 random audits on different hallways daily for 1 week, then bi-weekly for 4 weeks to monitor for PPE compliance.
- Compliance concerns to be addressed immediately by the DON and/or designee.
- Results of audits and reviews will be reported to and reviewed by QAPI committee monthly for three months.
Mechanical Lift Failure Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for residents requiring mechanical lifts for transfers, leading to an incident involving a resident who suffered a lumbar fracture and hemorrhage. The mechanical lift used for the resident's transfer was not in working order, and another lift that was out of order was not removed from the floor. This resulted in the lift falling on the resident, causing her to fall to the floor and sustain injuries. The resident involved was a female with a history of a wedge compression fracture, memory deficit following cerebral infarction, traumatic subarachnoid hemorrhage, and multiple sclerosis. She was dependent on staff for transfers and required a mechanical lift. On the day of the incident, two CNAs attempted to transfer her using a mechanical lift that had not been properly inspected or maintained, leading to the equipment failure and subsequent injury. Interviews with staff revealed a lack of communication and proper procedures for identifying and removing faulty equipment. The maintenance director did not document weekly inspections, and there was no formalized process for routine maintenance. Additionally, staff were not adequately trained to identify and report equipment issues, contributing to the unsafe use of the mechanical lift.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On multiple occasions, a staff member, referred to as [NAME] I, did not wear a hair restraint that fully covered her hair while preparing food. Additionally, she was observed wearing a surgical mask around her neck, with hair falling out from the hair net. Other staff members, such as DA K and NSS L, were also observed not wearing masks in the kitchen, which is against the facility's policy for maintaining hygiene and preventing contamination. The report highlights several instances where [NAME] I did not perform hand hygiene while preparing food. She was observed removing gloves and putting on new ones without washing her hands multiple times. This included handling food directly, such as mixing puree bread and preparing macaroni, with torn gloves or without changing gloves after touching different surfaces. These actions were contrary to the facility's policy, which requires hand hygiene before putting on gloves and after touching any contaminated surfaces. Interviews with various staff members, including DA K, NSS L, NSS M, and [NAME] J, confirmed that the facility's expectations for hand hygiene and the use of hair restraints were not met. They acknowledged that failing to perform hand hygiene and not wearing proper hair restraints could lead to cross-contamination and potential health risks for residents. The facility's policies on the use of gloves and hand washing, dated November 3, 2004, were reviewed and indicated that hands should be washed when entering the kitchen and before putting on gloves, as well as after removing gloves or touching contaminated surfaces.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of five residents by not ensuring that their call lights were within reach while they were lying in bed. This deficiency was observed in multiple instances for each resident, indicating a pattern of neglect in providing necessary access to call lights, which are crucial for residents to request assistance. The lack of accessible call lights was noted during various times of the day, and in some cases, residents were observed in distress or unable to call for help due to the call lights being out of reach. Resident #39, a female with intact cognition, reported that her call light often fell out of reach, making it difficult to receive timely care. She recounted an incident where she was sick and unable to call for help for two hours because her call light was not accessible. Similarly, Resident #159, who has severe cognitive impairment and is completely dependent for activities of daily living, was observed with her call light out of reach on multiple occasions, raising concerns about her ability to call for help if needed. Other residents, such as Resident #80, who has mild to moderate cognitive impairment, and Resident #94, who has severe cognitive impairment, were also found without accessible call lights. Resident #80 was observed crying in bed without her call light and reported a fall during the night when she could not find it. Resident #94, who requires total assistance, was found with her call light on the floor, and an interview attempt revealed she was unresponsive. Resident #17, who is totally dependent on staff, was observed with her call light tucked behind her mattress, making it inaccessible. Interviews with staff, including the DON and Administrator, confirmed that call lights should always be within reach, yet this standard was not consistently met, leading to the deficiency.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and time frames to meet their mental and psychosocial needs. Specifically, the care plans for Resident #3, Resident #73, and Resident #97 were not adequately updated or developed. Resident #3 did not have a care plan in place within 21 days of admission, while Resident #73 and Resident #97's care plans lacked updates on activity preferences and dental status after their quarterly assessments. Resident #73, an elderly female with Alzheimer's disease, generalized anxiety disorder, and cognitive communication deficit, had no documented preferences for activities or information regarding her dental status in her care plan. Observations and interviews revealed that her dentures were loose, and she did not wear her top denture. Despite these issues, her care plan was not updated to reflect her current needs and preferences. Similarly, Resident #97, who had cerebral infarction, unspecified dementia, and bipolar disorder, did not have her activity preferences updated in her care plan, despite her participation in various activities like coloring and dancing. The facility's policy requires that a comprehensive, person-centered care plan be developed within seven days of the completion of the required MDS assessment and no more than 21 days after admission. However, interviews with staff, including the MDS coordinator and the Director of Nursing, revealed a lack of clarity and responsibility regarding who should update the care plans. This lack of coordination and communication among staff members contributed to the deficiencies in the care planning process, potentially placing residents at risk of not receiving necessary care and services.
Failure to Maintain Resident Dignity and Hygiene
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the lack of daily clothing changes for several residents. Resident #3, Resident #59, and Resident #97 were observed wearing the same clothing over multiple days, from January 14 to January 17, 2025. Despite the residents' varying levels of assistance required for dressing, there were no documented attempts to assist them with changing clothes during this period. Interviews with staff revealed that while some residents, like Resident #59, had a history of refusing care, there was no consistent documentation or care planning to address these refusals effectively. Additionally, the facility failed to maintain a clean and odor-free environment for Resident #15. On January 14, 2025, Resident #15's room was observed to have a strong odor of urine, which persisted until it was reported and addressed later in the day. Staff interviews indicated that residents are supposed to be checked every two hours, and any odors should be promptly addressed to prevent potential health issues such as UTIs or skin breakdown. However, the initial failure to address the odor in Resident #15's room suggests a lapse in the facility's adherence to its hygiene and care protocols. The facility's policies and staff interviews highlight the expectation that residents' clothing should be changed daily and that any refusals of care should be documented and addressed through care planning. However, the lack of documentation and care planning for residents who refuse care, as well as the failure to maintain a clean environment for Resident #15, indicate deficiencies in the facility's implementation of these policies. These deficiencies potentially compromised the residents' dignity and quality of life.
Resident Restrained in Wheelchair Without Justification
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which is a violation of their right to be treated with respect and dignity. The resident, a female with Alzheimer's and a history of wandering, was observed on multiple occasions in a wheelchair with the wheels locked, positioned against a desk or table, which prevented her from getting out. This situation was identified as a restraint, as it restricted the resident's movement and posed a risk of injury. Despite the facility's claim that the locked wheels served as a reminder for the resident not to stand, the resident was observed attempting to stand and nearly fell on several occasions. Interviews with facility staff, including a CNA, a nurse, the DON, and the ADM, revealed a lack of awareness and training regarding the use of restraints. The CNA and nurse both stated that residents should not be restrained and acknowledged the potential for injury if restraints were used. The DON and ADM also recognized that locking a resident in a wheelchair against a desk or table constituted a restraint, yet there was no restraint policy or training in place at the facility. This deficiency affected one resident directly and had the potential to impact other residents by contributing to restricted movement and psychological distress.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the prevention of abuse and neglect, as evidenced by an incident involving two residents. Resident #95, a man with severe cognitive impairment and a history of peripheral vascular dementia, was slapped on the shoulder by Resident #97, a woman with mild cognitive impairment and a history of bipolar disorder. The incident occurred after Resident #97 entered Resident #95's room, despite previous attempts to prevent such occurrences by providing a safety device to Resident #95. The incident was observed by a surveyor, but LVN T, who was notified of the incident, failed to follow the facility's incident procedures. Interviews with various staff members, including CNAs and LVNs, revealed inconsistencies in the understanding and implementation of the facility's abuse and neglect policies. While some staff members stated they would report such incidents immediately, others were unsure of the frequency of their training or the exact procedures to follow. The Director of Nursing (DON) and the Administrator (ADM) also provided insights into the facility's expectations and procedures, indicating that altercations should be reported immediately and investigated to determine if they are reportable to the Health and Human Services Commission (HHSC). The facility's policy on accidents and incidents, dated May 2016, requires immediate completion of an incident report upon staff awareness of an occurrence involving a patient. The policy also mandates a psychosocial well-being assessment for patients with potential psychosocial changes resulting from an incident. Despite these policies, the failure to report and properly address the incident between Resident #95 and Resident #97 highlights a deficiency in the facility's implementation of its abuse and neglect prevention protocols.
Failure to Maintain Nutritional Status Leads to Resident's Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, leading to significant weight loss and potential health risks. The resident, an elderly female with multiple health conditions including congestive heart failure and severe cognitive impairment, was not consistently weighed, and her care plan was not updated to reflect her nutritional needs. Despite being on a regular ground diet, there were no orders for regular weight monitoring, and her food intake was not accurately recorded, contributing to her weight loss. Observations and interviews revealed that the resident was not receiving adequate assistance with meals, which was crucial given her dependence on others for activities of daily living. Staff members, including a certified medication aide and a speech-language pathologist, acknowledged the resident's poor meal intake and weight loss but failed to take appropriate actions or communicate effectively with the healthcare team. The resident's dietitian had not seen her in person and was unaware of the extent of her weight loss, while the director of nursing was not informed of the lack of weight monitoring or the resident's significant weight loss. The facility's failure to provide necessary oversight and intervention for the resident's nutritional needs resulted in a decline in her health condition. The resident's responsible party noted the lack of assistance with meals and incorrect meal trays, which further exacerbated the situation. The facility's inaction and lack of communication among staff members contributed to the resident's deteriorating condition, highlighting deficiencies in the care provided to maintain her nutritional status.
Failure to Remove Discontinued Medications and Reconcile Controlled Drugs
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication errors and discrepancies. For Resident #31, a male with end-stage Alzheimer's disease and other complex medical conditions, the facility did not remove discontinued controlled medications from the medication cart. Despite a hospice order to discontinue Klonopin due to a recent fall, the medication remained in the cart with 21 pills left, indicating a failure to follow proper procedures for medication discontinuation and disposal. Similarly, for Resident #35, a female with multiple diagnoses including dementia and a recent femur fracture, the facility did not properly reconcile controlled medications. Although Tramadol was discontinued, the medication cart still contained 26 pills, and the last administration was recorded months prior. This discrepancy was not addressed, and the medication was not disposed of as required. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of communication and adherence to facility policies regarding controlled medication management. The DON was unaware of the missing medications and expected to be notified of such discrepancies immediately. The facility's policy required immediate reporting and investigation of medication discrepancies, which was not followed, leaving the residents vulnerable to medication errors.
Failure to Document and Respond to Resident's Fall
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to a deficiency in quality of care. The resident, a female with dementia, pain, muscle weakness, and generalized anxiety disorder, experienced an unwitnessed fall. Despite being found on the floor multiple times, the necessary assessments and documentation were not completed by the nursing staff. LVN A did not document the fall, conduct neurological checks, or inform the oncoming nurse, which delayed the recognition of the resident's condition. The resident was found sitting on the floor on several occasions, and although aides and nurses were aware of her pain and difficulty standing, she was not sent to the emergency room until the following evening. The resident was diagnosed with a hip fracture at the hospital. The lack of documentation and communication among the staff contributed to the delay in providing necessary medical care. Interviews with staff revealed inconsistencies in reporting and documenting incidents, as well as a lack of adherence to the facility's policies on accidents, incidents, and changes in condition. The failure to follow professional standards of practice and the comprehensive person-centered care plan resulted in the resident not receiving timely and appropriate care.
Removal Plan
- Identify all patients with accident/incident reports
- Ensure accident/incident process is opened and have nurse open before returning to the floor
- Accidents and incidents discussed at stand up and stand down
- Ensure accident/incident process is opened, reports are completed, treatments are documented, process for unwitnessed falls have neuro checks initiated, and investigations are completed accordingly
- Audit accident/incident reports for completion
- In-services: Accidents/Incidents, Change of Condition, Pain, and MD notification
- Education: Pre/Post test on Accidents/Incidents, Pain, and Change of Condition
CNA Throws Cup at Resident, Violating Abuse Policy
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a CNA during breakfast time. The incident involved a CNA who, out of frustration, threw an empty juice cup that landed on the resident's lap. The resident, who has a severely impaired cognition with a BIMS score of 05, was unable to recall specific details of the incident but remembered experiencing pain. The CNA admitted to throwing the cup out of frustration due to the resident's behavior of taking another resident's juice, which she perceived as a risk of cross-contamination. Witnesses, including another CNA and the AD, confirmed the incident, noting that the resident screamed in pain when the cup hit his hand. The CNA who witnessed the event reported it to the DON, who then interviewed the involved CNA. The DON found the CNA's actions unacceptable and against the facility's abuse policy, leading to her suspension. The facility's policy emphasizes the residents' right to be free from abuse and outlines a commitment to protecting residents from such incidents. The resident involved in the incident has multiple diagnoses, including dementia, anxiety disorder, and schizophrenia, which contribute to his cognitive and physical vulnerabilities. Despite the incident, a subsequent assessment by an RN found no physical injuries on the resident. The psychology consultant also reported that the resident did not express any stress or reference the incident during a visit the following day.
Failure to Properly Store Nebulizer Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required nebulizer treatments. Observations revealed that the nebulizing masks and tubing for these residents were not stored in protective bags when not in use, contrary to the facility's policy. The masks were found to be exposed to the environment, foggy, and dirty, which could potentially lead to respiratory infections. The Licensed Vocational Nurse (LVN) confirmed that the equipment should have been sanitized and stored properly to prevent infections. Resident #2, a male with multiple diagnoses including hypertension, dementia, and heart failure, was receiving Albuterol sulfate via nebulization as needed. However, his care plan did not indicate any respiratory issues or the need for nebulizer medication. Resident #3, a male with chronic respiratory failure and COPD, was on oxygen therapy and received Budesonide and AR formoterol via nebulization. His care plan included interventions for oxygen therapy but did not address nebulizer use. The Director of Nursing (DON) acknowledged that staff were expected to comply with the facility's policy for nebulizer use and storage, and recognized the potential risk for respiratory infections due to this oversight.
Failure to Include Hospice in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's hospice services were included in the care planning process, which is a violation of the resident's rights to participate in their care planning. The resident, an elderly male with severe cognitive impairment due to senile dementia, was receiving hospice services. Despite this, the facility did not invite or notify the hospice service provider to participate in the interdisciplinary team (IDT) meetings held to discuss the resident's behaviors and potential alternative placement. Interviews with various staff members, including the administrator (ADM) and social worker (SW), revealed a lack of communication and coordination with the hospice service provider. The SW admitted to not inviting the hospice social worker to the IDT meeting, believing it was unnecessary. The hospice service provider was responsible for the resident's care, medications, and services, yet they were not involved in the care planning meetings, which could affect the resident's health and well-being. The facility's policies and agreements with hospice services clearly outlined the need for collaboration and communication with hospice representatives in care planning. However, the facility did not adhere to these policies, as evidenced by the lack of documentation of hospice involvement in the resident's care plan. The facility's failure to include the hospice service provider in the care planning process was acknowledged by the ADM, who admitted that the hospice should have been included in the IDT meeting.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not immediately notify the hospice service provider (HSP) about the resident's increase in aggressive behaviors and the need to transfer the resident due to these behaviors. The resident, an elderly male with severe cognitive impairment and diagnoses including senile degeneration of the brain and unspecified dementia, exhibited physical and verbal behavioral symptoms directed at others, which were not effectively communicated to the hospice team. The resident's care plan required staff to report any changes or declines in condition to the hospice service provider, but there were no notes indicating that the hospice was notified of the resident's behaviors or involved in care planning meetings. Interviews with facility staff and hospice representatives revealed a lack of communication and coordination between the facility and hospice services. Hospice nurses and social workers were not informed of the resident's incidents or invited to interdisciplinary team (IDT) meetings, which discussed the resident's behaviors and alternative placement. The facility's policy required immediate notification of the hospice about significant changes in the resident's status and collaboration with hospice representatives in the care planning process. However, the facility did not adhere to these policies, as evidenced by the lack of documentation and communication with the hospice team. This failure to involve hospice services in the care planning process could potentially place residents at risk of not receiving appropriate interventions, treatments, and care.
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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