Ralls Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Ralls, Texas.
- Location
- 1111 Avenue P, Ralls, Texas 79357
- CMS Provider Number
- 675407
- Inspections on file
- 43
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 17 (6 serious)
Citation history
Health deficiencies cited at Ralls Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was verbally and physically abused by night staff. While the resident sat alone in a wheelchair reading and watching TV, an LVN and a CNA told the resident to mind her own business, made comments about getting her removed from the facility, and turned off the dining and TV room lights to force her to bed. The CNA then pushed the resident’s wheelchair toward the hall despite her resistance, causing the resident to come out of the chair onto the floor. The LVN, that CNA, and another CNA subsequently placed a blanket over the resident, grabbed her forearm, and dragged her down the hall and into her room on the blanket while she told them to stop and struck out at them. The resident later reported being dragged down the hall, and bruising was documented on her forearm. None of the involved staff reported the incident at the time, even though they had been in-serviced that dragging a resident on a blanket and turning off lights to force bedtime constitute abuse.
A resident with severe cognitive impairment, psychosis, and behavioral disturbances alleged that night-shift staff turned off the TV while she was watching, forced her to go to bed, placed a blanket over her head, and dragged her down the hall to her room on the blanket, resulting in documented bruising to her forearm. The only staff on duty at the time—an LVN and two CNAs—continued working subsequent shifts and did not report the incident to administration, later stating they did not believe they had done anything wrong despite prior in-services on abuse, neglect, and resident rights that specifically identified dragging a resident on a blanket and forcing bedtime as abuse. The allegation was not brought to administrative attention until days later, when the resident reported it and video footage was reviewed, and the ADON and business office manager did not immediately report the allegation to the administrator before investigating, resulting in a failure to implement required abuse/neglect reporting policies and timeframes.
A resident with severe cognitive impairment and multiple psychiatric diagnoses alleged that night-shift staff verbally and physically abused her by turning off the TV, forcing her to go to bed, dumping her from a wheelchair, and dragging her down the hall on a blanket, resulting in documented bruising. An LVN and two CNAs involved in the incident did not report the event to the ADM or abuse coordinator and continued working subsequent shifts, including caring for the same resident, despite facility policies requiring immediate reporting of suspected abuse. The resident reported the incident two days later to the ADON and other CNAs, at which point leadership confirmed via video that the resident’s rights had been violated and that the conduct constituted verbal and physical abuse. The facility’s failure centered on staff inaction in recognizing and immediately reporting the abuse as required by the abuse, neglect, and exploitation policies.
A nurse wrongfully took multiple residents’ personal belongings, including perfume, skin care products, clothing, shoes, electronics, a wallet, ID, SS card, and financial cards, without their knowledge or consent. Video footage showed the nurse using a gate code and moving bags around the building and off the premises during night shifts. Most residents, including those with dementia and other psychiatric and visual impairments, did not realize items were missing; one cognitively intact resident reported missing personal items and a wallet. Staff interviews confirmed they had been trained that residents’ rights prohibit staff from borrowing or taking residents’ property, and the nurse’s personnel file showed completed training on resident rights and abuse/neglect/exploitation. Law enforcement later found the nurse in possession of stolen property and an elderly resident’s identification, while an inventory linked numerous recovered items in trash bags around the facility to several residents, demonstrating the facility’s failure to prevent misappropriation of residents’ belongings.
A medication aide administered several medications, including anticonvulsants, antihypertensives, and antipsychotics, to a resident who did not have physician orders for these drugs. The error occurred when the aide became distracted during medication pass, resulting in the resident receiving medications intended for another individual. The incident was promptly reported, and the resident was monitored and later transferred to the hospital for observation before returning to the facility.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft. Staff lacked adequate training and guidance, and there was insufficient oversight to ensure compliance, increasing the risk of such incidents occurring.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A CNA failed to follow proper hand hygiene protocols during incontinence care for a resident with a foley catheter, risking infection and cross-contamination. Despite regular training, the CNA did not change gloves or perform hand hygiene between handling soiled and clean items. Interviews with the DON and ADM confirmed the importance of these practices to prevent infection.
The facility failed to maintain a sanitary environment in the front entrance parking lot, as observed by an overflowing trashcan with Styrofoam containers, cups, and fast food bags. Interviews revealed a lack of systematic checks for outdoor trash disposal, with the Maintenance and Housekeeping Supervisor aware of the issue but preoccupied with other tasks. The Regional Director/Interim Administrator acknowledged the absence of a system for regular checks and planned to implement a check-off list for housekeeping staff.
A facility failed to protect residents from sexual abuse, with incidents involving residents with known histories of inappropriate behavior. A male resident with severe cognitive impairment was involved in two incidents of sexual misconduct, and another male resident with similar impairments engaged in inappropriate touching. The facility did not implement adequate protective measures or consistent monitoring, leading to a pattern of non-compliance and placing residents at risk.
The facility failed to implement its abuse and neglect policies, leading to unreported incidents of a resident's fall resulting in a hip fracture and multiple uninvestigated sexual incidents involving residents with dementia. The CNA did not report the fall, and the administration did not consider the sexual incidents reportable, placing residents at risk for continued harm.
A LTC facility failed to report multiple incidents of inappropriate sexual contact between residents with severe cognitive impairments. Despite the severity of the incidents, the administration did not report them, citing the residents' dementia as a reason for not considering it abuse. The DON and Administrator were aware but did not report to the state agency, and the Regional Director also failed to ensure reporting, despite acknowledging the expectation.
The facility failed to investigate incidents involving a resident's fall and inappropriate sexual contact between residents. A resident with cognitive impairments fell in the shower, resulting in a hip fracture, but the incident was not reported promptly. Additionally, inappropriate sexual contact between residents was not thoroughly investigated or reported, as the administration believed the behavior was not willful due to cognitive impairments.
A resident with severe cognitive impairment was involved in an inappropriate sexual incident with another resident. The facility staff intervened and placed the male resident under 1:1 monitoring, but failed to notify the female resident's family as required by policy. The family was not informed until days later, causing distress.
The facility failed to prevent a resident with a history of aggression from repeatedly entering another resident's room and causing harm. Despite multiple reports from staff and family members, the facility did not implement effective interventions, resulting in ongoing risk and harm to the residents involved.
The facility failed to address and resolve grievances related to a resident's aggressive behavior, which included physical aggression and wandering into other residents' rooms. Despite being aware of the issues, the facility did not document or follow up on the grievances, leading to unresolved issues and potential risks to residents' safety and well-being.
The facility failed to implement policies to prevent abuse, neglect, and exploitation of residents. A resident with severe cognitive impairment was repeatedly pulled out of bed and scratched by another resident with advanced dementia. Staff, including CNAs and the Administrator, did not report these incidents to the state agency in a timely manner, despite being trained to do so. The facility's inadequate monitoring and reporting systems placed residents at risk of harm.
The facility failed to update a resident's care plan to reflect ongoing physical and verbal aggressive behaviors. Despite multiple documented incidents, the care plan remained unchanged since January 2024. Interviews with staff revealed a lack of communication and monitoring, leading to the deficiency.
Resident Dragged on Blanket and Verbally Abused by Night Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical and verbal abuse and to ensure a safe environment free from abuse. The resident was an elderly female with Alzheimer’s disease, schizoaffective disorder (bipolar type), paranoid schizophrenia, generalized anxiety, intermittent explosive disorder, insomnia, conversion disorder with seizures/convulsions, muscle weakness, and difficulty walking. Her MDS showed a BIMS score of 6, indicating severe cognitive impairment, daily rejection of care, and psychosis with hallucinations and delusions. She used a wheelchair and had care plan focuses addressing aggressive behaviors, delirium risk, and mood problems, with interventions including simple communication, monitoring for agitation, and medication management. On the evening of the incident, video footage showed the resident sitting alone in the dining room in her wheelchair, reading a book or Bible and watching TV. LVN A and CNA B engaged in a verbal exchange with the resident after she told them to stop talking about someone; staff told her to “mind your business” and made repeated comments about finding another place for her to live and questioning why she had not been made to move. LVN A stated she was going to find a new place for the resident and that the resident could not stay there, and made a gesture with her hand across her neck while making a sound with her mouth. CNA B then repeatedly told the resident she needed to go to bed, turned off the dining room and TV room lights while the resident was reading and watching TV, and stood on a chair to turn off ceiling fan lights, despite the resident stating she did not want to go to bed and telling staff not to tell her what to do. The video further showed CNA B pushing the resident in her wheelchair toward the hall while the resident resisted by pushing her feet toward the ground and telling staff to stop. As the wheelchair was pushed, the resident reached for an overbed table and went forward out of the wheelchair onto the floor. Staff then left her on the floor at LVN A’s direction before discussing using a blanket to move her. The resident was observed on the floor, verbally telling staff to stop, and striking out at staff while they continued to interact with her. CNA B obtained a blanket, and together CNA B, LVN A, and CNA C placed the blanket over the resident; CNA B grabbed the resident’s forearm and began dragging her down the hall on the blanket while the resident attempted to hit and kick. CNA C grabbed the blanket at the resident’s feet and assisted CNA B in dragging the resident down the hall and into her room, while LVN A walked alongside and made comments including that the resident should be sent out. The resident later reported to the ADON that she had been dragged down the hall on a blanket when she refused to go to bed early, and a skin assessment documented bruising to her lower forearm. None of the three staff on duty reported the incident at the time, and they continued to work subsequent shifts with the resident before the incident was discovered via video review. Interviews with administrative staff corroborated that LVN A, CNA B, and CNA C verbally abused the resident, forced her toward her room in the wheelchair, pushed the wheelchair so hard that she came out of the chair onto the floor, and then wrapped her in a sheet or blanket and dragged her down the hall to her room while she was telling them to stop. The ADM and DON both described that the resident had been quietly reading her Bible and was not bothering anyone before staff decided she needed to go to bed, turned off the lights, and escalated the situation. The BOM’s review of the video confirmed that staff told the resident to mind her own business, threatened to get her out of the facility, turned off lights that were not normally turned off, pushed her in the wheelchair until she fell out, and then dragged her down the hall on a sheet or blanket. Staff interviews showed that LVN A believed using a blanket to move the resident was the safest option and did not consider it abuse, despite prior in-service training that dragging a resident down the hall on a blanket and turning off lights to force a resident to bed are forms of abuse. Other staff interviewed stated that residents should not be forced to go to bed, forcefully pushed in wheelchairs when refusing, or dragged on the floor to their rooms.
Failure to Implement Abuse Reporting Policies After Resident Dragged on Blanket
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures requiring that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property be reported immediately, and no later than two hours when abuse or neglect with bodily injury is alleged. A cognitively impaired female resident with Alzheimer’s disease, paranoid schizophrenia, schizoaffective disorder (bipolar type), generalized anxiety, intermittent explosive disorder, conversion disorder with seizures, insomnia, and a history of aggressive behaviors alleged that staff verbally and physically abused her. Her MDS showed a severely impaired BIMS score of 6, daily rejection of care, and psychosis with hallucinations and delusions, and she used a wheelchair. On 12/19, during the evening/night shift, the resident reported that staff turned off the TV while she was watching a show in the dining area, told her she had to go to bed, put a blanket over her head, grabbed her feet, and dragged her down the hall to her room on the blanket. She stated she stayed in her room that night and did not report the incident the following day. Progress notes documented by the ADON on 12/22 indicated that the resident voiced she had been dragged down the hall on a blanket when she refused to go to bed early, that staff turned off the TV and forced her, dumped her out of her wheelchair, and then dragged her down the hall. A skin assessment on 12/22 by the ADON documented bruising to the resident’s lower forearm, and the resident was not on blood thinners at the time. Interviews and timecard reviews established that LVN A, CNA B, and CNA C were the only staff on duty on the night of 12/19 when the incident occurred, and they continued to work subsequent shifts on 12/20 and 12/21 without reporting the incident to administrative staff. The DON stated the incident occurred around 7:00 PM on 12/19 and was not reported until 12/21, when it was discovered on facility video footage shortly after the same three staff started their shift. The ADM stated he had video of the incident, that LVN A, CNA B, and CNA C abused the resident, and that all three were implicated and failed to report the event. Interviews with the ADON and BOM showed that the resident’s allegation of abuse was not immediately reported to the Administrator prior to investigation. The BOM reported that on Sunday, as she was leaving work around 6:00 PM, the ADON called and relayed that the resident had reported an allegation of abuse but that the ADON did not know if it had occurred or which staff were involved. The BOM then reviewed the video, identified the incident and the involved staff, and notified the ADM, ADON, and corporate nurse. The ADON later acknowledged that, based on policy, she expected staff to report any abuse immediately and that staff did not follow the abuse, neglect, and exploitation policy when they failed to report the abuse the night it happened. Statements typed by administration for LVN A, CNA B, and CNA C documented that they admitted to dragging the resident down the hall on a blanket and did not believe they had done anything wrong, citing the resident’s behaviors and medication noncompliance. Despite existing policies and prior in-service training on abuse, neglect, resident rights, and the requirement to report abuse, the incident was not reported within the required timeframe, and the facility failed to ensure that its abuse/neglect reporting policies were implemented for this resident. The facility’s written Abuse, Neglect, Exploitation, Misappropriation Prevention Program policy, revised April 2021, stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the program includes identifying and investigating all possible incidents of abuse, neglect, mistreatment, or misappropriation and reporting any allegations within required federal timeframes. Interviews with multiple staff (including CNAs, LVNs, and the ADON) confirmed they had received training on abuse and neglect, reporting abuse, and resident rights, including explicit instruction that dragging a resident down the hall on a blanket and turning off lights or TV to force a resident to go to bed are forms of abuse and violations of resident rights. Nonetheless, on the night of the incident, LVN A, CNA B, and CNA C did not report the event, and the ADON and BOM did not immediately report the resident’s allegation to the Administrator before initiating review of the video. This sequence of actions and inactions led to the identified deficiency that the facility failed to implement its abuse/neglect reporting policies and procedures for this resident.
Removal Plan
- Conduct safe surveys.
- Provide in-service training on abuse and neglect, resident rights, and misappropriation.
- Review in QAPI and discuss with staff.
- Monitor camera footage across shifts to monitor staff.
Failure to Immediately Report and Remove Staff After Alleged Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an allegation of abuse was reported immediately, as required by policy and federal regulations, and that involved staff were removed from contact with the resident pending investigation. A cognitively impaired female resident with Alzheimer’s disease, schizoaffective disorder, paranoid schizophrenia, intermittent explosive disorder, and other psychiatric and neurologic diagnoses alleged that staff verbally and physically abused her. She reported that while she was watching television in the dining room, night-shift staff turned off the television and told her she had to go to bed, then dumped her out of her wheelchair, placed a blanket over her head, grabbed her feet, and dragged her down the hall to her room. A subsequent skin assessment documented bruising to her lower forearm, and she was not on blood thinners at the time of the incident. The incident occurred during a night shift when an LVN and two CNAs were the only staff on duty. According to the DON and ADM, these three staff members were captured on video dragging the resident down the hall on a blanket and were determined to have verbally and physically abused her and violated her resident rights by forcing her to go to bed and turning off the lights. Despite this, none of the three staff reported the incident to the Administrator or other facility leadership at the time it occurred or at any point during the following shifts. They continued to work their full night shift immediately after the incident and returned for subsequent night shifts, continuing to provide care to the same resident without reporting the event. The resident did not report the abuse on the day following the incident and remained in her room, later stating that she told staff to leave her alone. Two days after the incident, she reported to the ADON and other CNAs that staff had dragged her to her room and turned off the television. The ADON, who had been trained on abuse, neglect, and resident rights, stated that based on facility policy she expected staff to report any abuse immediately and acknowledged that staff did not follow the abuse, neglect, and exploitation policy requiring immediate reporting to the Administrator or designee. Interviews with the LVN involved revealed that she believed she had not done anything wrong, did not recognize dragging the resident on a sheet as abuse, and did not report the incident. The facility’s written policies clearly defined abuse, required immediate reporting of suspected abuse by any staff member, and prohibited actions such as unreasonable confinement and willful infliction of injury or mental anguish, but these requirements were not followed by the involved staff, resulting in the failure to immediately report the alleged abuse and to protect the resident from further contact with the alleged perpetrators. The noncompliance was identified as Past Noncompliance (PNC) with Immediate Jeopardy that began on 12/19/25 and ended on 01/07/26. The Immediate Jeopardy related to the failure to report the alleged abuse immediately and to remove the involved staff from resident care while the incident remained unreported and uninvestigated.
Failure to Prevent Misappropriation of Residents’ Personal Property by RN
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from misappropriation of personal property by a staff member, RN D. Several residents had intact or impaired cognition and varying levels of dependence for activities of daily living, including residents with paraplegia, Alzheimer’s disease, depression, anxiety, and other psychiatric and visual conditions. One cognitively intact resident reported that personal items such as a decorative wine bottle with flowers, signs, containers with flowers and markers, and unopened face cream were missing from her room. Another resident reported a missing wallet and ID, and staff assisted in searching for these items before they were later found among property returned in trash bags. Video footage and staff interviews revealed that RN D used a code to unlock and enter a side gate, placed bags in a wheelchair, moved around the building with bags in hand, and exited and re-entered through the gate while carrying bags. The Administrator and Business Office Manager described that large trash bags were later found outside the facility near gates and around the exterior, and that these bags contained clothing, jewelry, electronics, shoes, perfume, cologne, and other items. An inventory list documented that items in the bags were identified as belonging to five residents, including perfume, skin care products, a cash app card, ID card, Social Security card, iPad, phone, wallet, clothing, shoes, and a razor with guards and bag. Interviews with the DON, Administrator, Business Office Manager, and other staff established that residents, other than the one who reported a missing wallet and personal items, generally did not know their belongings were missing and had not reported losses. Staff stated they had received training on resident rights and understood that residents should not be forced to do anything against their will and that staff should not borrow, use, or take residents’ personal items. Despite this, RN D, who had documented training on resident rights and abuse, neglect, exploitation, and misappropriation, wrongfully took residents’ belongings over a period of time while working night shifts and transporting items out of the building, resulting in misappropriation of property for at least five residents. Law enforcement involvement confirmed that RN D was found in possession of stolen property and identification belonging to an elderly resident, and he was to be charged with multiple counts of theft and a felony related to possession of an elderly person’s identification. The facility’s own policies defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent and stated that residents have the right to be free from misappropriation and exploitation. The events described show that, despite these policies and staff training, the facility did not prevent RN D from taking and wrongfully using residents’ personal property, resulting in the cited deficiency for failure to protect residents from misappropriation of their belongings. Safe surveys conducted with residents after the incident documented that residents reported feeling safe and did not identify concerns or fear of staff, and multiple staff interviews reiterated their understanding that taking residents’ belongings was prohibited. However, these measures and understandings did not prevent the misappropriation that had already occurred. The deficiency centers on the fact that residents’ personal property, including identification and personal effects, was taken without their knowledge or consent by a nurse employed at the facility, and the facility only became aware of the scope of missing items when they were returned in trash bags and identified as belonging to specific residents.
Medication Administration Error Involving Wrong Resident
Penalty
Summary
A medication aide (MA) administered multiple medications, including Tegretol, Lipitor, Baclofen, Metoprolol, Neurontin, and Quetiapine Fumarate, to a resident who did not have physician orders for any of these medications. These medications were prescribed for another resident, not the one who received them. The error occurred while the MA was passing medications and became distracted due to the presence of residents near the medication cart, which he had previously expressed caused him difficulty concentrating. The MA immediately recognized the error and reported it to the Assistant Director of Nursing (ADON) and Director of Nursing (DON). The resident who received the incorrect medications had a complex medical history, including Alzheimer's disease with early onset, essential hypertension, cognitive communication deficit, intermittent explosive disorder, psychotic disorder with hallucinations, dry eye syndrome, acute atopic conjunctivitis, and muscle weakness. At the time of the incident, the resident was observed to be active and alert, both before and after the medication error. Following the administration of the wrong medications, the resident was monitored, and her vital signs remained stable. However, the physician later ordered her transfer to the hospital for close observation. Facility records and interviews confirmed that the resident did not have any physician orders for the medications administered in error. The facility's policies required staff to verify resident identity and medication details before administration, but these procedures were not followed in this instance. The error was documented in the medication error report, and the incident was confirmed through interviews with the MA, ADON, DON, and other staff members. The resident was subsequently discharged from the hospital with no new orders and returned to her baseline condition.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through review of facility documentation and staff interviews, which revealed that the required policies and procedures were either not in place or not consistently followed. The lack of clear guidance and enforcement contributed to an environment where incidents of abuse, neglect, or theft could occur without adequate prevention or timely intervention. Surveyors found that staff were not adequately trained or informed about the necessary steps to identify, report, and prevent such incidents, and there was insufficient oversight to ensure compliance with regulatory requirements.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper hand hygiene practices of a CNA during incontinence care for a resident. The resident, a cognitively intact male with a history of malignant neoplasm of the prostate, epilepsy, and atrial fibrillation, was observed receiving care that did not adhere to proper infection control protocols. Specifically, the CNA did not change gloves or perform hand hygiene after handling soiled materials and before touching clean items, such as a clean brief, during the care process. Interviews with the CNA, DON, and ADM revealed that while handwashing training is conducted regularly, the CNA did not follow the established procedures during the observed care. The CNA acknowledged the mistake and attributed it to nervousness. The DON and ADM confirmed the importance of hand hygiene and glove changes between tasks to prevent infection and cross-contamination, as outlined in the facility's hand hygiene policy.
Facility Fails to Maintain Sanitary Conditions in Parking Lot
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment on its grounds, specifically in the front entrance parking lot. Observations made on multiple occasions throughout the day revealed a trashcan near the front entrance that was overflowing with trash, including Styrofoam food containers, cups, fast food bags, and other miscellaneous items. The trashcan's lid could not close due to the volume of trash, and this situation persisted for at least five hours. Interviews with the Maintenance and Housekeeping Supervisor and the Regional Director/Interim Administrator revealed a lack of a systematic approach to ensure regular checks and timely disposal of trash in outdoor areas. The Maintenance and Housekeeping Supervisor acknowledged awareness of the overflowing trashcan but was preoccupied with other tasks and did not address it immediately. He also noted that most housekeeping staff were new and still undergoing training. The Regional Director/Interim Administrator confirmed the absence of a system to regularly check outdoor trashcans and mentioned plans to create a check-off list for housekeeping staff. The facility's policy, revised in May 2008, stated that grounds should be maintained in a safe and attractive manner, with maintenance responsible for keeping the grounds free of litter.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse, as evidenced by multiple incidents involving inappropriate sexual behavior by residents with known histories of such behavior. Resident #2, a male with severe cognitive impairment and a history of wandering and aggressive behavior, was involved in two separate incidents of sexual misconduct. On one occasion, he was found with his penis in Resident #3's hand, and on another, he was discovered in bed with Resident #4, with his hand in her pants. Despite these incidents, the facility did not implement adequate protective measures or consistent monitoring to prevent further occurrences. Resident #5, another male resident with severe cognitive impairment and a history of inappropriate sexual behavior, was involved in incidents of kissing and touching other residents without consent. Despite these behaviors, the facility failed to provide adequate supervision or intervention to prevent further inappropriate conduct. The lack of timely and effective response to these incidents highlights a significant deficiency in the facility's ability to protect residents from abuse. Interviews with staff revealed a lack of communication and training regarding the supervision and management of residents with known behavioral issues. The facility's administration and nursing staff did not consistently implement or monitor protective measures, such as 1:1 supervision, even after incidents of sexual misconduct were reported. This failure to act appropriately and promptly placed residents at risk of further abuse and demonstrated a pattern of non-compliance with regulations designed to ensure resident safety.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse and neglect, as evidenced by several incidents involving multiple residents. One significant incident involved a resident who fell in the shower while being assisted by a CNA. The CNA did not report the fall to the nursing staff, resulting in a delay in medical assessment and treatment. The resident sustained a hip fracture, which was only discovered later when the resident complained of pain. Interviews revealed that the CNA believed the incident was not reportable and did not follow the care plan, which required two staff members for transfers. Additionally, the facility failed to report and investigate multiple sexual incidents involving residents. In one case, a male resident was found with his pants unzipped and his penis in the hand of a female resident, who appeared to be asleep. The incident was not reported to the state agency, and the facility did not conduct a thorough investigation. The facility's administration did not consider the incident reportable due to the residents' dementia, and no immediate protective measures were taken. The facility's inaction placed residents at risk for continued abuse and neglect, as well as potential harm and mental anguish. The lack of proper reporting and investigation procedures, along with the failure to follow care plans, contributed to the deficiencies identified by the surveyors. These failures highlight significant gaps in the facility's ability to protect its residents and ensure their safety and well-being.
Failure to Report Inappropriate Sexual Incidents in LTC Facility
Penalty
Summary
The facility failed to report multiple incidents of inappropriate sexual contact between residents, which were not reported to the proper authorities as required by state law. The incidents involved residents with severe cognitive impairments, including dementia and Alzheimer's disease. The facility did not report these incidents within the mandated two-hour timeframe, which is required when the events involve abuse or result in serious bodily injury. This failure to report was observed in five out of nine residents reviewed for abuse and neglect. The first incident involved a male resident with severe cognitive impairment and a history of wandering and aggressive behavior, who was found with his pants unzipped and his penis in the hand of a female resident who was asleep. Despite the severity of the incident, the facility's administration did not report it, citing the dementia of both residents as a reason for not considering it abuse. The Director of Nursing (DON) and the Administrator were aware of the incident but did not take the necessary steps to report it to the state agency. Subsequent incidents involved the same male resident and other female residents, as well as another male resident with a history of sexual dysfunction and aggressive behavior. These incidents were also not reported, with the facility's administration again citing the cognitive impairments of the residents involved. Interviews with staff revealed a lack of clear communication and understanding of the reporting requirements, with some staff expressing concerns about the incidents but being overruled by higher management. The Regional Director, who was consulted, also failed to ensure that the incidents were reported, despite acknowledging the expectation that they should have been.
Failure to Investigate Incidents of Abuse and Neglect
Penalty
Summary
The facility failed to investigate several incidents involving residents, leading to deficiencies in addressing potential abuse and neglect. One incident involved a fall that occurred with a resident while in the care of a CNA. The resident, who had a history of cerebral infarction, major depressive disorder, and cognitive communication deficit, fell in the shower and sustained a hip fracture. Despite the resident's care plan indicating the need for assistance from two staff members during transfers, the CNA attempted the transfer alone. The incident was not reported to the nursing staff immediately, resulting in a delay in treatment and assessment. Another series of incidents involved inappropriate sexual contact between residents. A resident with dementia and a history of behavioral issues was found in a compromising situation with another resident. Despite the severity of the incident, the facility did not conduct a thorough investigation or report the incident to the appropriate authorities. The administration's decision not to report was based on the belief that the behavior was not willful due to the residents' cognitive impairments. The facility's administration and nursing staff failed to follow established protocols for investigating and reporting incidents of potential abuse and neglect. Interviews with staff revealed a lack of communication and understanding of the importance of reporting such incidents. The administration relied on guidance from a regional director, which led to the decision not to report the incidents, despite the potential risks to resident safety.
Failure to Notify Family of Inappropriate Sexual Incident
Penalty
Summary
The facility failed to immediately inform the representative of a resident involved in an incident of inappropriate sexual behavior. The incident involved a male resident who was found in a female resident's room, engaging in inappropriate sexual conduct. The staff intervened and placed the male resident under 1:1 monitoring, but the family of the female resident was not notified of the incident as required by facility policy. The female resident, who was involved in the incident, had a history of Alzheimer's disease, cognitive communication deficit, and major depressive disorder, which left her severely cognitively impaired and dependent on staff for her needs. The incident was documented by an LVN, who reported it to the Director of Nursing (DON) but failed to notify the resident's family. Interviews with staff revealed that the charge nurse was responsible for notifying the family, but this did not occur. The facility's policy on abuse investigation and reporting requires that the resident's representative be informed of any incidents involving abuse or mistreatment. Despite this policy, the family member of the female resident was not informed until several days after the incident, leading to distress and dissatisfaction. The facility's administration acknowledged the oversight but did not provide a clear explanation for the failure to notify the family promptly.
Failure to Prevent Resident Aggression and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility staff, including the Administrator and DON, did not adequately address the ongoing behavior of one resident entering another resident's room, leading to physical altercations. This failure involved a resident with severe cognitive impairment and another resident with a history of physical and verbal aggression, resulting in multiple incidents where the aggressive resident entered the other resident's room and caused harm, including pulling the resident out of bed and causing scratches and abrasions. The aggressive resident had a documented history of combativeness, wandering, and aggression, yet was not placed on special supervision until after a significant incident occurred. Despite multiple reports from staff and family members about the aggressive resident's behavior, including attempts to pull the other resident out of bed and physical aggression towards staff, the facility did not implement effective interventions to prevent these incidents. The care plans and progress notes indicated that the aggressive resident's behavior was known, but the facility's response was inadequate, leading to repeated incidents. Interviews with staff, family members, and the residents involved revealed that the facility's actions were insufficient to prevent the aggressive resident from entering the other resident's room. Staff reported the incidents to their supervisors, but no effective measures were put in place to address the behavior. The facility's failure to implement appropriate supervision and interventions resulted in ongoing risk and harm to the residents involved.
Failure to Address and Resolve Grievances Related to Resident Aggression
Penalty
Summary
The facility failed to address, resolve, and promptly resolve grievances in accordance with its policy for a resident, a family member, and a staff member. The facility did not document, resolve, or follow up on grievances related to the behavior of another resident, which included physical aggression and wandering into other residents' rooms. This failure involved multiple incidents where the aggressive resident pulled another resident out of bed, causing fear and potential harm. The aggressive resident had a history of combativeness, wandering, verbal aggression, and physical aggression, which was documented in his care plan and progress notes. Despite these documented behaviors, the facility did not implement effective interventions to prevent further incidents. The facility's staff, including CNAs and the DON, were aware of the aggressive resident's behavior but did not take adequate steps to address the grievances raised by the affected resident, his family member, and the staff. Interviews with the affected resident, his family member, and staff revealed that the facility's administration and nursing staff were aware of the ongoing issues but failed to take appropriate actions. The facility's grievance log did not contain any records related to the concerns raised about the aggressive resident's behavior. The facility's policies on grievances and resident rights were not followed, leading to unresolved issues and potential risks to residents' safety and well-being.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility staff, including the Administrator, failed to report incidents between two residents to the governing state agency. The incidents involved Resident #1, who had severe cognitive impairment and required maximum assistance, and Resident #2, who had advanced dementia and a history of aggressive behavior. On multiple occasions, Resident #2 entered Resident #1's room, resulting in physical altercations where Resident #1 was pulled out of bed and scratched. These incidents were not reported in a timely manner to the state agency as required by the facility's policies. The report details that on one occasion, Resident #2 pulled Resident #1 out of bed, causing scratches and abrasions. Despite the severity of the incident, the facility staff, including CNAs and LVNs, failed to report the abuse immediately to the abuse coordinator. The Administrator was also found to have not reported the incident to the state agency. Interviews with staff revealed that there was confusion and a lack of immediate action in reporting the abuse, even though the staff had been trained to do so. The DON and ADM were aware of the incidents but did not take appropriate steps to ensure timely reporting and intervention. Further interviews and record reviews indicated that Resident #2 had a history of wandering and aggressive behavior, which was known to the facility staff. Despite this, adequate measures were not taken to prevent further incidents. The facility's failure to implement effective monitoring and reporting systems placed residents at risk of harm. The ADM admitted to not being fully aware of the ongoing issues between Resident #1 and Resident #2 and did not implement additional interventions outside of medication adjustments and monitoring from psychiatric services. This lack of action and oversight contributed to the deficiency in preventing and reporting abuse and neglect in the facility.
Failure to Update Resident's Care Plan for Aggressive Behaviors
Penalty
Summary
The facility failed to ensure the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for a resident with a history of dementia, depressive disorder, mood disorder, and blindness in one eye. Despite the resident's ongoing incidents of physical and verbal aggressive behaviors, the care plan was not updated to reflect these changes, potentially placing the resident and others at risk of harm. The resident's records revealed multiple incidents of physical and verbal aggression, including pulling another resident out of bed, hitting staff with a walking stick, and wandering into other residents' rooms. These behaviors were documented in progress notes and provider investigation reports, yet the care plan remained unchanged since January 2024. The MDS Coordinator and other staff members were aware of these incidents but did not update the care plan accordingly. Interviews with the MDS Coordinator, ADM, and DON indicated a lack of communication and monitoring regarding the resident's care plan. The MDS Coordinator stated that she would revise the care plan if informed of changes in the resident's behavior, but she was unaware of the extent of the resident's aggression. The ADM and DON acknowledged the importance of updating care plans but were also unaware that the resident's care plan had not been revised. The facility's policy requires care plans to be updated with significant changes in the resident's condition, but this was not followed in this case.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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