Pflugerville Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pflugerville, Texas.
- Location
- 521 S Heatherwilde Blvd, Pflugerville, Texas 78660
- CMS Provider Number
- 675913
- Inspections on file
- 52
- Latest survey
- January 6, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Pflugerville Care Center during CMS and state inspections, most recent first.
A cognitively impaired male resident with schizophrenia, major depressive disorder, and generalized anxiety disorder became upset during care when a CNA controlled his bed remote and did not comply with his request. During in-room care with two other CNAs present, the resident used profanity toward the CNA, and the CNA responded by yelling back and using profane, derogatory language, including statements about cleaning the resident and asserting her own rights. Other CNAs reported hearing the CNA curse at the resident, and the LVN on duty was informed of an altercation and spoke with the resident about what occurred. In a later interview, the CNA admitted repeating the resident’s profane remarks back to him. The facility’s abuse policy defined verbal abuse as willful use of disparaging or derogatory language toward a resident, and the CNA had previously been trained on abuse/neglect and resident rights.
Staff were observed serving food trays to residents without performing hand hygiene between each resident. Two newly hired CNAs admitted to forgetting to use hand hygiene despite having received training. Other staff, including an LVN and the DON, confirmed that hand hygiene is required by facility policy when serving meals.
The facility did not ensure accurate documentation of overnight care for four residents, including one on hospice who was found deceased, with no records of care or monitoring from 10:00 p.m. to 6:00 a.m. Staff interviews revealed inconsistent understanding of documentation expectations, and review of records showed missing entries for required ADL assistance and monitoring, despite care plans mandating frequent checks and interventions.
A resident with multiple medical and cognitive conditions was issued a discharge notice for non-payment, but the facility did not provide a discharge summary, plan, or adequate notification to the resident, responsible party, or ombudsman. The discharge notice lacked a specific destination, and staff interviews revealed no finalized discharge plan or proper communication, contrary to facility policy.
The facility failed to update the care plans for three residents to reflect changes in their activity levels, placing them at risk of not having their needs reviewed and revised appropriately. The Activity Director acknowledged that the care plans should have been revised to reflect the residents' current activity needs, as the lack of updates could affect their quality of life and mood.
The facility failed to provide adequate personal hygiene and grooming for three residents, leading to deficiencies in nail care and facial hair management. A resident with severe cognitive impairment was found with unclean and uneven fingernails, while another resident with Alzheimer's disease had unclean and rough nails. Additionally, a female resident with multiple health conditions was observed with facial hair, indicating a lack of adherence to grooming care plans. Staff interviews revealed inconsistencies in care documentation and awareness of care schedules.
The facility failed to ensure the Dietary Manager (DM) wore a beard guard properly while in the kitchen, as observed over three days. The DM was seen with facial hair visible during food preparation and service, contrary to the facility's dress code policy. Interviews confirmed that hair restraints are required to prevent contamination, and the DM is responsible for enforcing this policy.
A facility failed to maintain an effective infection control program as Student Nurse A and Student Nurse Aide G did not perform hand hygiene between resident interactions during meal service. They touched contaminated surfaces before handling food for multiple residents, despite being trained on infection control. Staff interviews confirmed the expectation for hand hygiene to prevent cross-contamination, which was not adhered to, posing a risk of bacterial contamination.
The facility failed to serve meals to residents in a timely and organized manner, affecting their dignity and quality of life. Three residents were served at different times, contrary to the facility's policy of serving all residents at a table before moving to the next. The DON and ADM acknowledged the lack of communication between nursing and dietary staff, which led to this issue.
A facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including toxic encephalopathy and parkinsonism, who was at risk for falls. The care plan required a fall mat beside the bed and the bed in the lowest position, but observations showed the mat was not consistently in place, and the bed was not always lowered. Staff interviews confirmed the expectation for fall mats to be in place, but the facility did not adhere to this requirement.
The facility failed to provide individualized activities for three residents with cognitive and physical impairments, leading to a deficiency in meeting their well-being needs. Despite care plans requiring one-on-one activities, these residents received minimal engagement, with staff acknowledging the difficulty in providing consistent activities due to facility constraints.
A resident with multiple health conditions did not have his meal preferences obtained or RD recommendations for snacks and supplements implemented, leading to dissatisfaction with meals and potential health risks. The facility failed to follow its policy on meal service and snacks, and the discontinuation of nutritional supplements was done without proper consultation.
The facility failed to properly store Probiotics in the medication refrigerator on the secure unit, where they were kept with staff food and drinks. Staff interviews revealed that all staff had access to the refrigerator, and there was no temperature log maintained. The Director of Nurses acknowledged that medications should not be stored with food and drinks and that the Probiotics should have been in the medication room.
A resident with severe cognitive impairment did not receive meals according to his preference for large portions, as documented in his care plan and physician orders. Despite expectations for dietary staff and nurses to ensure meal tickets matched the meals served, the resident received a normal portion size, contrary to his documented preferences.
A resident with dementia and a history of falls was moved by a CNA without a nurse's assessment after an unwitnessed fall, contrary to facility policy. The CNA panicked and moved the resident to a wheelchair, risking potential harm. The resident was later assessed by an LVN and found uninjured.
A resident with osteoporosis was not transferred according to her care plan, resulting in her sliding to the ground and sustaining femur fractures. Staff failed to use a hoyer lift as required, and the incident was not documented or assessed as a fall. The resident later died from complications following surgery. The facility's policies on transfer protocols and documentation were not adhered to, leading to this deficiency.
A resident in an LTC facility was not transferred according to her care plan, which required a hoyer lift with two-person assistance. Instead, staff attempted to transfer her without the lift, resulting in her sliding to the ground. The incident was not immediately reported or documented, and the resident later developed bilateral femur fractures, leading to her death after surgery. Staff interviews revealed a lack of awareness of the resident's transfer status and failure to adhere to facility policies.
The facility failed to document and report changes in skin condition for two residents, both with severe cognitive impairment. One resident had a dark purple blister on his finger, and another had a bruise and skin tear, none of which were documented in their charts. Staff interviews revealed a lack of awareness and documentation, contrary to facility policies requiring skin assessments and notifications.
A resident on Eliquis was unable to undergo a scheduled tooth extraction because the facility failed to hold the medication as recommended. Despite the resident's request for dental services due to pain, the procedure was canceled, causing ongoing discomfort and frustration. Interviews revealed a breakdown in communication and procedure adherence, as the recommendation to hold the blood thinner was not properly entered into the system.
The facility failed to provide adequate supervision to prevent falls for two residents, resulting in one resident sustaining a hip fracture. Despite having care plans with specific fall prevention interventions, the facility did not consistently implement these measures, and fall risk assessments were not completed as required.
The facility failed to meet PASARR requirements for a resident who needed a customized manual wheelchair (CMWC). The wheelchair was approved on 2/15/24, but the facility did not order it until 2/26/24, missing the 2/22/24 deadline. This delay caused a postponement in the resident receiving her Medicaid Entitled Service, impacting her ability to participate in necessary therapies and mobility activities.
Verbal Abuse of Cognitively Impaired Resident by CNA During Care
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA during personal care. The resident was an adult male with schizophrenia, major depressive disorder, and generalized anxiety disorder, and had a BIMS score of 06 on a recent MDS, indicating severely impaired cognition. His care plan noted a potential for verbally abusive behaviors, with an intervention to notify the charge nurse of any abusive behaviors. On the day of the incident, the resident became upset when a CNA did not change the television channel as requested, and later during care an altercation occurred between the resident and the CNA. According to written statements from two CNAs, three CNAs, including the alleged perpetrator, were in the resident’s room to change him. One CNA reported that after they finished changing the resident, the involved CNA began cursing at the resident, telling him, "fuck me, no fuck yourself, you stupid ass. I have rights just like you," and appeared very upset. Another CNA stated that the resident had asked for the bed remote control, that it dropped on him, and that he yelled "Fuck you!" at the CNA. This CNA reported that the involved CNA yelled back at the resident, saying, "We are here cleaning your ass! Don't tell us Fuck you!," and that both the resident and the CNA were yelling at each other. The LVN on duty documented that a CNA reported the altercation to him and that he then spoke with the resident, who described what had happened. In a subsequent phone interview, the involved CNA acknowledged that she was assisting two other CNAs, that the bed remote dropped on the resident, and that the resident called her an "ugly fucking face." She stated that she told the resident he was not to speak to her that way and repeated his words back to him, and that the other CNAs only heard her repeating those words. The administrator later confirmed that an investigation determined the CNA had been verbally abusive to the resident, and that the CNA had previously received training on abuse/neglect and resident rights. The facility’s Abuse/Neglect Policy defined verbal abuse as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to the resident.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff on the 500 Hall were observed distributing and serving food trays to residents without performing hand hygiene between residents. Specifically, two CNAs were seen passing food trays, touching residents' doors, setting up trays, and moving the food cart without cleaning their hands between each resident. Both CNAs were new to the facility and reported having received hand hygiene training during orientation, but admitted to forgetting to perform hand hygiene during meal service. Interviews with additional staff, including an LVN, another CNA, and the DON, confirmed that facility policy requires hand hygiene before and after assisting residents with meals. The LVN and DON both acknowledged that failure to perform hand hygiene when serving food constitutes an infection control issue. Review of the facility's hand hygiene policy also indicated that hand hygiene is required before and after assisting a resident with meals.
Failure to Document Overnight Care for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate and complete documentation of care provided to four residents during the overnight shift from 10:00 p.m. to 6:00 a.m. on the dates reviewed. For one resident who was on hospice care and found deceased around 6:00 a.m., there was no documentation of care provided during the night, nor any record of a change in condition that would have required intervention. The resident's care plan required two CNAs for bed mobility and mechanical lift transfers, and staff were expected to provide incontinent care and repositioning at least every two hours. However, the resident's progress notes, medication administration records, and point-of-care documentation lacked entries for the entire overnight period, except for a single set of vital signs recorded at 1:27 a.m. The postmortem assessment indicated the resident was found unresponsive, cold to the touch, and with fixed and dilated pupils, with no evidence of care or monitoring during the preceding shift. Similarly, three other residents, all with significant cognitive and physical impairments and dependent on staff for all activities of daily living, had no documentation of care provided during the same overnight shift. Their care plans also required frequent assistance, including turning, repositioning, and incontinent care at least every two hours. Review of their point-of-care records revealed no entries for any care activities during the specified time frame. Staff interviews confirmed that CNAs and nurses were responsible for providing and documenting care at least every two hours, and that documentation was expected to be completed in the electronic health record after each task. Interviews with staff, including CNAs, nurses, the ADON, and the medical director, revealed inconsistent understanding of the facility's expectations for resident checks and documentation frequency. While some staff stated that care should be provided and documented every two hours, others were unclear about the specific requirements. The facility lacked a formal policy on rounding or checking on residents, and the documentation policy emphasized the need for timely, accurate, and complete entries in the clinical record. Despite these expectations, the absence of documentation for multiple residents during the overnight shift indicated a failure to maintain accurate medical records in accordance with professional standards.
Failure to Provide Proper Discharge Documentation and Planning
Penalty
Summary
The facility failed to properly discharge a resident by not providing all necessary information and documentation required for a safe and effective transition of care. The resident, who had significant medical and cognitive impairments including vascular dementia, major depressive disorder, type 2 diabetes with neuropathy, and bilateral below-knee amputations, was not his own responsible party. The facility issued a discharge notice for non-payment but did not document a discharge summary, discharge plan, or provide adequate notification to the resident, responsible party, or ombudsman. The discharge notice also lacked a specific address for the resident's discharge destination. Record review showed no evidence of discharge planning discussions or documentation in the nursing progress notes. Interviews with facility staff revealed that the discharge process was still ongoing, with no finalized plan or summary in place. The ombudsman and responsible party were not properly informed, and there was confusion among staff regarding the resident's discharge status and destination. The resident expressed concerns about not receiving sufficient help with his Medicaid application and uncertainty about his ability to return home, while the responsible party indicated the resident's previous home was uninhabitable and that family support was unavailable. Facility policy requires documentation of the basis for discharge and a plan to ensure a safe transition, but these steps were not followed. The lack of a documented discharge summary, plan, and proper notification could compromise the resident's continuity of care and transition to an appropriate setting, as the facility had not determined a safe discharge location or communicated effectively with all involved parties.
Failure to Update Care Plans for Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for three residents were reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for three out of eight residents reviewed for care plans. The care plans for these residents were not updated to reflect changes in their activity levels, which placed them at risk of not having their needs reviewed and revised as necessary to ensure appropriate care. Resident #47, a female with cerebral palsy, severe intellectual disabilities, and autism, had a care plan that did not reflect her need for one-on-one activities. Despite her activity preference for watching cartoons and listening to music, her care plan was not updated to indicate her need for individualized activities. The Activity Director acknowledged that the care plan should have been revised to reflect these needs, as the lack of updates could affect the resident's quality of life, potentially leading to feelings of isolation or depression. Similarly, Resident #59, who had diagnoses including Alzheimer's disease and chronic pain, was not provided with an updated care plan to reflect her need for one-on-one activities. Although her activity participation record indicated she required one-on-one interaction five days a week, this was not documented in her care plan. The Activity Director admitted that the care plan should have been revised to match the resident's current activity needs. Resident #70, with vascular dementia and visual impairments, also had a care plan that was not updated to reflect her preference for one-on-one visits in her room. The Activity Director confirmed that the care plan should have been revised to document this preference, as the lack of documentation could lead to the resident being encouraged to participate in activities she did not prefer, potentially affecting her mood and behavior.
Deficiencies in Personal Hygiene and Grooming for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #20, a male with severe cognitive impairment and multiple health conditions, was observed with unclean and uneven fingernails, despite requiring assistance with personal hygiene. The care plan for Resident #20 included regular nail care, but observations revealed a lack of adherence to this plan, as the resident's nails were not properly maintained. Similarly, Resident #77, a female with Alzheimer's disease and severe cognitive impairment, was found with unclean and rough fingernails. Despite the care plan specifying the need for assistance with personal hygiene, including nail care, the resident's nails were not adequately maintained. Interviews with staff indicated a lack of awareness regarding the last time the resident's nails were trimmed or cleaned, and there was no documentation of refusal of care by the resident. Resident #56, a female with severe cognitive impairment and multiple health conditions, was observed with facial hair, indicating a failure to provide adequate grooming. The care plan required regular shaving during scheduled showers, but the resident was observed with facial hair over several days. Interviews with staff revealed inconsistencies in documenting care refusals and a lack of adherence to the care plan. The Director of Nursing acknowledged the expectation for female residents to be shaved unless otherwise documented, but there was no explanation for the lack of documentation regarding the resident's refusal of care.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the use of hair restraints in the kitchen. Observations over three consecutive days revealed that the Dietary Manager (DM) did not properly wear a beard guard, leaving facial hair visible while serving and preparing food. This was noted during lunch meal service and food preparation activities, where the DM was seen with the beard guard down under the chin, contrary to the facility's dress code policy. Interviews with the DM, Director of Nursing (DON), and Administrator (ADM) confirmed that hair restraints, including beard guards, are required for all kitchen staff to prevent hair from contaminating food. The DM acknowledged the requirement but could not explain why he failed to comply. Both the DON and ADM emphasized that the DM is responsible for ensuring compliance with hair restraint policies in the kitchen. The facility's dress code policy mandates that dietary staff with facial hair must wear beard nets while in the dietary department.
Inadequate Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of Student Nurse A and Student Nurse Aide G. During a lunch tray pass, Student Nurse A was observed delivering meal trays to multiple residents without performing hand hygiene between each interaction. She touched contaminated surfaces such as her shirt, wheelchair armrests, and the clothes of other residents before handling the food of Residents #33, #44, #7, and #36. Despite being in-serviced on hand hygiene and infection control, she admitted to possibly forgetting to sanitize her hands during the process. Similarly, Student Nurse Aide G was observed delivering meal trays in the dining room without washing or sanitizing his hands after touching potentially contaminated surfaces, including his scrub top and the armrests of wheelchairs. He handled the food of Residents #17 and #51 without performing hand hygiene, acknowledging the potential for cross-contamination. Despite receiving training on infection control and hand hygiene, he failed to adhere to the facility's policies during the meal service. Interviews with facility staff, including LVN B, the DON, and the ADM, confirmed that the expectation was for all staff to perform hand hygiene between each resident interaction to prevent cross-contamination and potential illness. The facility's policies on hand hygiene and infection control were not followed, leading to a risk of bacterial contamination and potential gastrointestinal illness among residents.
Failure to Ensure Timely Meal Service for Residents
Penalty
Summary
The facility failed to treat residents with respect and dignity during meal service, affecting three residents. Resident #15, a male with severe cognitive impairment and multiple health issues, was served his meal at 12:00 PM, but no other residents in the dining room were served until 12:50 PM. Resident #50, a female with intact cognition and various health conditions, was served at 12:23 PM and was sitting alone. Resident #52, a female with severe cognitive impairment and several health diagnoses, was served at 12:37 PM while sitting with three other residents. The facility's dining room etiquette policy requires that all residents at a table be served before moving to another table, which was not followed. The Director of Nursing (DON) acknowledged that it is best practice for all residents to be served meals simultaneously, but this did not occur due to a lack of communication between nursing and dietary staff. The Administrator (ADM) also stated that it was expected for each table to be completely served before moving to the next, and that communication between nursing staff and the Dietary Manager (DM) was necessary to ensure this. The failure to serve meals in a timely and organized manner could place residents at risk of diminished dignity and affect their quality of life. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, and promoting an environment that enhances their quality of life. However, the observed meal service did not align with these standards, as residents were served at different times, leading to potential feelings of neglect or isolation.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's needs. The resident, a male with multiple diagnoses including toxic encephalopathy, malignant neoplasm of the temporal lobe, major depressive disorder, parkinsonism, hypertension, GERD, and cerebral edema, was at risk for falls due to an unsteady gait and combative behavior. The care plan specified that the bed should be in the lowest position with a fall mat in place beside the bed. However, observations revealed that the fall mat was not consistently placed beside the bed as required, and the bed was not always in the lowest position. Interviews with staff, including a CNA and the DON, confirmed that the fall mat was supposed to remain on the floor beside the resident's bed when the resident was in bed. The DON acknowledged that the fall mat was not consistently in place and could not explain why it was moved. The ADM also stated that the expectation was for fall mats to be in place to prevent significant injuries from falls. The facility's policy required the development and implementation of a comprehensive care plan to meet the resident's needs, but this was not adhered to, as evidenced by the improper placement of the fall mat and bed position.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of three residents, leading to a deficiency in meeting their physical, mental, and psychosocial well-being. Resident #47, a female with cerebral palsy, severe intellectual disabilities, and autism, was supposed to receive one-on-one activities three times per week. However, during the months of January to March 2025, she only received such activities on two occasions. Observations showed that she was often left without stimulation in her room, and the Activity Director admitted to not knowing how to accommodate her communication needs. Resident #70, a female with vascular dementia and severe visual impairment, was also supposed to receive one-on-one activities three times per week. Despite her preferences for listening to music and being around animals, she only received one-on-one activities sporadically, with no visits recorded in March 2025. The Activity Director acknowledged the difficulty in providing consistent activities due to the facility's census and did not provide a reason for the lack of activities for Resident #70. Resident #59, a female with Alzheimer's disease and a language barrier, was to receive one-on-one activities five days a week. However, there was no documentation of her receiving any such activities during February and March 2025. The Activity Director noted that Resident #59's physical decline made it difficult for her to participate in group activities, and her family requested she not be isolated in her room. The lack of activities for these residents was confirmed by interviews with staff, who noted the residents' need for culturally and mentally appropriate activities.
Failure to Implement Resident's Dietary Preferences and RD Recommendations
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not obtain the resident's meal preferences, which is a critical component of personalized care. The resident, who has a history of alcohol dependence with alcohol-induced dementia, anemia, hypertension, hyperlipidemia, muscle wasting, and chronic kidney disease, expressed dissatisfaction with the food, stating it was cold and unpalatable. The resident also reported never having been consulted about meal preferences and not receiving snacks between meals, which he found necessary due to frequent hunger. The facility also failed to implement and monitor the registered dietitian's (RD) recommendations for snacks with protein and Med Pass 2.0, a nutritional supplement, which were ordered but later discontinued without proper communication or documentation. The Director of Nursing (DON) acknowledged that the orders were discontinued without consulting the RD or physician, despite the resident being under his ideal body weight (IBW). The resident had refused the Med Pass 7 out of 24 times it was administered, which led to the discontinuation of the orders without exploring alternative supplements. Interviews with the Dietary Manager (DM) and the Administrator (ADM) revealed a lack of clarity and responsibility in obtaining and updating the resident's dietary preferences and implementing RD recommendations. The DM admitted to not having a dietary profile for the resident and acknowledged the potential negative impact on the resident's intake and health. The ADM confirmed that it was the DM's responsibility to obtain meal preferences and that the failure to do so could lead to decreased intake and weight loss. The facility's policy on meal service and snacks was not followed, as the resident did not receive the recommended snacks or have his preferences recorded and honored.
Improper Storage of Medications with Staff Food
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, specifically Probiotics, in the medication refrigerator located in the secure unit's dining room. The Probiotics were stored alongside staff food and open drink containers, which is against the facility's medication storage policy. Interviews with staff, including an LVN and a CNA, revealed that all staff had access to the refrigerator, and they were aware that medications should be locked but could not recall the date of their in-service training on this policy. Additionally, there was no temperature log for the refrigerator on the secure unit, and the LVN confirmed that temperatures were not documented. The Director of Nurses stated that the Probiotics should have been stored in the medication refrigerator in the medication room, not on the secure unit, and acknowledged that it was not best practice to store medications with staff food and drinks. The facility's medication storage policy was requested but not provided at the time of the survey exit.
Failure to Honor Resident's Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodates a resident's preferences, specifically for a resident who requested large portions as per his care plan and meal ticket. The resident, who had a severely impaired cognition with a BIMS score of 5, was on a regular diet with a preference for large portions and no pork. Despite these documented preferences, the resident received a normal portion size meal, which did not align with his care plan or physician orders. Interviews with the Dietary Manager, Director of Nurses, and RN A revealed that there was an expectation for the dietary staff and nurses to ensure that meal tickets matched the residents' meals. The Dietary Manager and Director of Nurses confirmed that the resident was expected to receive double portions, and the nurse was responsible for checking the meal ticket against the meal tray. However, this process was not followed, leading to the resident not receiving the correct meal portions as per his preferences and care plan.
Failure to Assess Resident Before Moving After Fall
Penalty
Summary
The facility failed to ensure that a resident received appropriate assessment and care following an unwitnessed fall. A resident, who had a history of dementia, repeated falls, and age-related physical debility, was found on the floor by a CNA. Despite knowing the protocol, the CNA panicked and moved the resident to a wheelchair without first having a nurse assess him. This action was contrary to the facility's policy, which requires a nurse to assess a resident for potential injuries before moving them after a fall. The resident's care plan indicated a high risk for falls, and the facility's policy emphasized the importance of nurse assessment to prevent further injury. The CNA admitted to the mistake, acknowledging the importance of a nurse's assessment in such situations. The incident was reported to the nurse practitioner, and the Director of Nursing confirmed that the resident was later assessed by an LVN and found to be uninjured. However, the initial failure to follow protocol could have placed the resident at risk of harm.
Failure to Follow Transfer Protocols Leads to Resident's Injury and Death
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who was diagnosed with age-related osteoporosis, was supposed to be transferred using a hoyer lift with two-person assistance. However, on two occasions, the resident was not transferred according to her transfer status. On the first occasion, LVN A and CNA B attempted to transfer the resident without the hoyer lift, resulting in the resident sliding to the ground. Subsequently, LVN A, CNA B, and CNA C transferred her from the ground to the bed without using the hoyer lift. Approximately 24 hours after the inappropriate transfer, the resident's legs were swollen, red, and warm to the touch. She was transferred to the emergency room, where she was diagnosed with two femur fractures. During surgery to repair the fractures, the resident suffered an embolism and passed away. The facility also failed to ensure that LVN A completed a fall assessment or documented the incident after the resident slid to the ground during the inappropriate transfer. Interviews with staff revealed that they were unaware of the resident's transfer status and did not consider the incident a fall at the time. The facility's policies on hydraulic lift usage, fall prevention, and documentation were not followed, leading to the resident's injury and subsequent death. The noncompliance was identified as past non-compliance, and the immediate jeopardy situation began and ended on specific dates, with the facility correcting the noncompliance before the survey began.
Failure to Follow Transfer Protocols Leads to Resident's Injury and Death
Penalty
Summary
The facility failed to ensure a safe environment for a resident, who was supposed to be transferred using a hoyer lift with two-person assistance. On two occasions, the resident was not transferred according to her transfer status. During the first incident, a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA) attempted to transfer the resident without the hoyer lift, resulting in the resident sliding to the ground. Subsequently, the resident was transferred back to her bed without the use of the hoyer lift, contrary to her care plan requirements. Approximately 24 hours after the inappropriate transfer, the resident exhibited symptoms of swelling, redness, and warmth in her legs. She was then transferred to the emergency room, where she was diagnosed with bilateral femur fractures. During surgery to repair the fractures, the resident suffered an embolism and passed away. The facility's failure to follow the resident's transfer protocol and the lack of immediate incident reporting and assessment contributed to the resident's injuries and subsequent death. Interviews with staff revealed a lack of awareness and adherence to the resident's transfer status. The LVN involved admitted to not realizing the resident required a hoyer lift and failed to report the incident immediately. The CNAs involved also did not verify the resident's transfer status before attempting the transfer. The facility's policies on hydraulic lift usage, fall prevention, and documentation were not followed, leading to the resident's fall and the subsequent failure to provide necessary medical assessment and documentation.
Failure to Document and Report Skin Changes
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not identify bruising and changes in skin condition for two residents, which could place them at risk of not receiving necessary medical care, harm, and hospitalization. Resident #1, an elderly man with severe cognitive impairment and thrombocytopenia, was observed with a dark purple blister on his right middle finger, which was not documented in his chart or skin assessments. Similarly, Resident #2, an elderly woman with severe cognitive impairment, was found with a bruise on her left wrist and a skin tear on her left arm, which were not documented in her chart or skin assessments. Interviews with staff revealed a lack of awareness and documentation regarding the residents' skin conditions. LVN D, who was responsible for Resident #1, was unaware of the blister and found no documentation in the resident's chart. Similarly, LVN D was also unaware of the bruise and bandage on Resident #2 and found no documentation regarding these issues. CNAs A, B, and C stated that they would report any changes in a resident's skin to a nurse immediately, but there was no evidence that this was done for the two residents in question. RN G and LVN E stated that they would document any changes in skin condition and notify the necessary parties, but this was not reflected in the residents' records. The facility's policies and procedures for documenting and reporting changes in residents' skin conditions were not followed. The Director of Nursing (DON) and the Administrator (ADM) stated that it was their expectation for staff to complete a skin assessment, notify the physician, and document any changes in the residents' clinical records. However, there was no evidence that these steps were taken for the two residents. The facility's failure to document and report changes in skin condition could lead to a lack of appropriate medical care and intervention for the affected residents.
Failure to Hold Blood Thinner Leads to Cancelled Dental Procedure
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care in accordance with professional standards of practice and the resident's care plan. The resident, who was on Eliquis, a blood thinner, was scheduled for a tooth extraction. However, the facility did not hold the medication as required, leading to the cancellation of the procedure. This oversight resulted in the resident experiencing ongoing pain and frustration due to the inability to proceed with the necessary dental work. The resident, who was cognitively intact and had a history of spastic quadriplegic cerebral palsy, epilepsy, bipolar disorder, and major depressive disorder, had requested dental services due to tooth pain. Despite being placed on antibiotics for a chronic abscess, the extraction could not be performed because the facility did not follow the recommendation to hold the blood thinner. The resident expressed significant discomfort and dissatisfaction with the facility's handling of the situation, feeling neglected and in pain. Interviews with facility staff revealed a breakdown in communication and procedure. The nurse practitioner had advised that the blood thinner should be held, but this was not communicated effectively or entered into the system as an order. The Director of Nursing acknowledged the lapse, noting that the recommendation to hold the medication was not converted into an actionable order. This failure in communication and procedure adherence led to the resident's continued pain and frustration.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for two residents reviewed for falls. Resident #1, an elderly female with severe cognitive impairment and multiple risk factors for falls, fell and sustained a hip fracture requiring surgical intervention. Despite having a care plan with specific fall prevention interventions, the facility did not consistently implement these measures, as evidenced by the lack of completed fall risk assessments between incidents and the failure to ensure all interventions were in place at the time of the fall. Resident #1's care plan included various interventions such as keeping the bed in the lowest position, using a fall mat, ensuring the call light was within reach, and encouraging the use of non-skid footwear. However, on the day of the fall, the resident attempted to transfer herself from her wheelchair to her bed without assistance, resulting in a fall that caused a femoral fracture. The CNA who discovered the fall had previously assisted the resident to the toilet and reminded her to use the call button, but the resident did not call for help before attempting the transfer. Resident #2, who had a history of hemiplegia and muscle wasting, also had a care plan with fall prevention measures. However, the facility failed to complete the required fall risk assessments for this resident as well. The DON acknowledged that the new EMR system did not trigger quarterly fall risk assessments, leading to a gap in monitoring and updating care plans. This oversight contributed to the facility's failure to adequately supervise and prevent falls for both residents.
Failure to Timely Order Customized Manual Wheelchair
Penalty
Summary
The facility failed to ensure that Preadmission Screening and Resident Review (PASARR) federal requirements were met for a resident who required a customized manual wheelchair (CMWC). The resident, who has multiple diagnoses including Mild Cognitive Impairment, Intellectual Disability, and Peripheral Vascular Disease, was approved for a CMWC on 2/15/24. According to the Texas Administrative Code, the facility had five business days to order the wheelchair, with a deadline of 2/22/24. However, the wheelchair was not ordered until 2/26/24, after the facility received an email reminder from the PASRR team. This delay caused a postponement in the resident receiving her Medicaid Entitled Service. During an observation on 3/1/24, the resident was found lying in bed and mentioned that she was waiting for the wheelchair to get up. Interviews with the facility's administration revealed that they were aware of the delay and had taken steps to correct it on the same day they were notified by the state. The facility currently lacks a Minimum Data Set (MDS) nurse, and the Regional RN has been assisting with MDS needs. The delay in ordering the wheelchair placed the resident at risk of not achieving or maintaining her highest practicable level of physical functioning, as she was unable to participate in necessary therapies and mobility activities in a timely manner.
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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