Reunion Plaza Senior Care And Rehabilitation Cente
Inspection history, citations, penalties and survey trends for this long-term care facility in Texarkana, Texas.
- Location
- 1401 Hampton Rd, Texarkana, Texas 75503
- CMS Provider Number
- 675444
- Inspections on file
- 40
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Reunion Plaza Senior Care And Rehabilitation Cente during CMS and state inspections, most recent first.
During a COVID-19 outbreak, the facility failed to ensure staff consistently followed its infection control policies for PPE use, hand hygiene, and isolation. Staff, including a CNA, an AC, an LVN, and the Dietary Manager, entered COVID-positive rooms and passed meal trays wearing only surgical or KN95 masks without required gowns, gloves, or eye protection, and in some cases moved between COVID-positive and non-COVID rooms without changing PPE or performing hand hygiene. PPE carts for multiple COVID-positive residents lacked N95 masks, gloves, and face shields/goggles, and one LVN performed a blood sugar check and then administered enteral medications without changing gloves or sanitizing hands. Residents involved had serious conditions such as COPD, cancer, cerebral palsy, stroke, fractures, neutropenia, and feeding tubes, and were on droplet/respiratory isolation per orders and care plans, but the ordered precautions and facility policies were not consistently implemented.
A resident with Alzheimer’s disease had an unplanned discharge, and her legal representative submitted a written request, with a signed HIPAA authorization, for comprehensive medical and administrative records, including Medicaid-related correspondence, care plans, nursing and medication logs, and incident reports. Facility staff acknowledged receiving the request, but the Medical Records staff forwarded it to the Administrator and corporate attorney rather than processing it through the designated records request system, and there was no process to monitor the request after it was sent. The facility’s attorney later stated the request had been overlooked, resulting in the resident’s representative not receiving the requested records within required timeframes.
A resident with bowel and bladder incontinence, dependent for ADLs but cognitively intact, reported being cleaned only once per shift and sometimes going more than a full day without incontinent care, with staff placing blankets under her to catch urine. Surveyors observed two CNAs performing pericare with poor hand hygiene, including one CNA not washing hands before care and another washing only once, and proceeding without hand sanitizer. The resident’s brief was found completely saturated with a strong ammonia odor, and the resident stated she had not been changed since early morning and that her skin was sore. During care, the CNA wiped from the buttocks toward the vagina multiple times with the same wipe contaminated with BM, contrary to facility policy requiring wiping from vagina to anus with single-use strokes. The CNA later admitted she had not done pericare correctly and cited staffing issues, while the DON and Administrator stated expectations for timely, policy-compliant pericare to prevent infection.
Three residents experienced unsafe conditions during facility van transport, including falls due to improper wheelchair securement and unsafe driving by the van driver. One resident fell to the van floor when not secured with a seatbelt, another reported erratic driving, and a third was injured when the wheelchair tipped over after not being properly hooked in. The van driver failed to report incidents or follow emergency procedures, despite having received training on transport safety.
The facility did not provide or implement an infection prevention and control program, as required, with surveyors noting the absence of documentation or observed infection control practices.
Two residents with cognitive impairments eloped from a facility due to inadequate supervision and risk management. One resident, with severe cognitive impairment and Parkinson's, left unsupervised and was found at a local restaurant after crossing a busy road. Another resident, with dementia and a history of violent behavior, attempted to leave multiple times and fell outside the facility. Both incidents highlighted the facility's failure to provide adequate supervision and implement effective elopement prevention measures.
A facility failed to ensure that residents' drug regimens were free from unnecessary medications due to incorrect diagnoses being associated with their medication orders. One resident had diabetes medications linked to heart failure, while another had hypertension and pain medications associated with type 2 diabetes. A third resident's medications were incorrectly linked to acute kidney failure. This misalignment could lead to inappropriate treatment and monitoring.
A resident with hypertension and other conditions was administered antihypertensive medications despite blood pressure readings being below the prescribed parameters. The facility staff failed to notify the physician when the resident's blood pressure was outside the ordered range, leading to significant medication errors.
The facility failed to follow the posted menus and ensure proper portion sizes during two lunch meals, leading to potential nutritional inadequacies for residents. Substitutions were made without proper documentation, and staff interviews revealed dissatisfaction with portion sizes and menu adherence.
The facility failed to maintain food safety and sanitation standards, with unlabeled and undated food, carbon build-up on cookware, and improperly sealed containers. Food was served without temperature checks, and the Dietary Manager did not practice proper hand hygiene. The juice dispenser was also unclean. Staff interviews confirmed these practices did not align with facility policies.
The facility failed to provide palatable and properly heated meals, as reported by several residents and a family member. Meals were often cold, bland, and inconsistently cooked. Staff interviews revealed that the cook and Dietary Manager were responsible for ensuring food quality, but recent menu changes were not well-received. A test meal confirmed issues with food temperature and taste.
A facility failed to maintain effective infection control practices, as staff did not change gloves or perform hand hygiene during resident care. Two CNAs providing catheter care to a resident with multiple health issues did not follow proper glove use protocols. Similarly, a CNA assisting with incontinent care for a resident with Alzheimer's disease failed to change gloves and perform hand hygiene, risking cross-contamination. Interviews with facility staff confirmed the importance of hand hygiene, but observed practices did not align with facility policies.
A resident with severe cognitive impairment and high fall risk did not have her call light within reach, as observed over several days. Despite staff acknowledging the importance of call light accessibility, the resident's call light was often found hanging in the headboard or on the floor, contrary to the facility's policy.
The facility did not update the survey results book in the lobby, leaving the most recent state visit result outdated. The RNC and Administrator acknowledged the oversight, with the Administrator responsible for ensuring the book was current. This failure could prevent residents and families from being informed about past and current violation findings.
A facility failed to conduct a PASRR review for a resident with a new diagnosis of major depressive disorder. The resident did not receive the necessary evaluation and services due to the facility's oversight. Interviews revealed a lack of knowledge and coordination among staff regarding the PASRR process, and the facility's policy did not address updating PASRR Level 1 after a new diagnosis.
A resident with cerebral infarction and hemiplegia was not consistently assisted with transfers from bed to chair, despite her requests and care plan requirements. The facility's failure to provide necessary assistance led to the resident being confined to bed for a month, causing emotional distress and potential health risks. Staff interviews revealed a lack of adherence to the facility's ADL care policy.
A resident with severe pressure ulcers did not receive proper care due to incorrect settings on her pressure-relieving mattress, which was set for 250 pounds instead of her actual weight of 155 pounds. Observations confirmed the incorrect settings over several days, and interviews revealed confusion among staff about who was responsible for ensuring the correct settings. This oversight placed the resident at risk for further skin breakdown.
Two residents received inadequate perineal and catheter care, leading to potential risks of urinary tract infections. A resident with multiple diagnoses, including a UTI, was not properly cleaned during catheter care, and another resident with Alzheimer's was found with feces on her thigh, indicating improper incontinence care. Staff did not follow the facility's care policies, compromising infection control measures.
A resident with severe cognitive impairment and on enteral feeding experienced significant weight loss due to the facility's failure to follow the dietician's recommendations for Glucerna 1.5 and weekly weight monitoring. Staff were unaware of these recommendations, leading to a lack of action on the resident's nutritional needs.
The facility failed to ensure appropriate diagnoses and behavior monitoring for two residents prescribed psychotropic medications. One resident received Escitalopram without a proper diagnosis, while another lacked behavior monitoring for multiple psychotropic drugs. Staff interviews revealed lapses in documentation and adherence to facility policies on psychotropic drug use.
A resident's food preferences were not accommodated by the facility, despite clear communication of desired breakfast items. The resident did not receive requested boiled eggs on multiple occasions, and meal choices were not consistently obtained by the 2nd shift CNAs. The Dietary Manager and other staff acknowledged the issue, which was not aligned with the facility's policies on meal customization.
A resident with dementia and anxiety disorder was left exposed to the hallway by a CNA who failed to cover her and close the door after being asked to leave the room. The incident was confirmed by facility staff, highlighting a deficiency in maintaining the resident's dignity and privacy.
Two residents in an LTC facility experienced deficiencies in their care plans. A resident with Alzheimer's was observed without a required pillow in her wheelchair, risking comfort and skin integrity. Another resident with cerebral infarction had inadequate documentation of her meal intake, hindering nutritional monitoring. Staff interviews highlighted lapses in following care plan interventions and documentation responsibilities.
A facility failed to ensure accurate administration of Hydralazine for a resident with hypertension, as repeated identical blood pressure and pulse readings suggested checks were not performed. The resident's care plan required monitoring before each dose, but staff interviews confirmed the same readings could indicate falsification, risking potential harm.
The facility failed to update care plans for four residents following significant changes in their conditions, such as aggressive behavior and falls with injuries. Despite documentation of these incidents, care plans lacked necessary interventions, leaving staff without guidance. The MDS Coordinator and DON acknowledged the importance of timely updates, but the facility's policy was not followed.
A resident with complex medical conditions, including dialysis, was denied her request to be sent to the hospital by an agency nurse, LVN M, who deemed her medically stable. Despite the resident's self-reported symptoms of confusion and hallucinations, and her family's repeated calls, the nurse refused to call an ambulance, citing medical advice. The incident highlighted a failure to respect the resident's right to self-determination.
Two residents in a long-term care facility were subjected to abuse by CNAs. One resident's wheelchair was shaken during incontinent care, while another resident's wheelchair was forcefully pushed across a hallway. Both residents had severe cognitive impairments, and the incidents were witnessed by other staff members. The facility's abuse policy was not adhered to, leading to potential harm to the residents.
A resident with multiple health conditions was discharged from an LTC facility without proper discharge planning, resulting in a lack of necessary DME and medication instructions. The resident's early discharge was not communicated to home health or DME providers, leading to her readmission to the hospital. The facility's discharge policy was not followed, compromising the resident's safety at home.
A resident with severe cognitive impairment and high elopement risk exited a facility unsupervised and fell from his wheelchair, sustaining a head injury. Despite staff awareness of his risk and attempts to monitor him, the incident occurred during a busy meal service when supervision was insufficient. The facility's fall prevention measures were inadequate to prevent the accident.
A resident with sepsis and other conditions did not receive prescribed IV meropenem on time due to oversight in discharge orders and lack of follow-up by staff. The medication was delayed by three days, although the resident continued to receive vancomycin during dialysis. No acute issues were noted, and the missed doses were not deemed harmful by the NP.
Failure to Implement PPE, Hand Hygiene, and Isolation Practices During COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during a COVID-19 outbreak, including failure to ensure staff consistently followed facility policies for PPE use, hand hygiene, and isolation practices. Surveyors observed multiple instances where staff entered COVID-positive residents’ rooms or provided services to them without the required PPE. A certified nursing assistant (CNA) passed meal trays on a COVID-positive hall without wearing a gown, gloves, N95 mask, or face shield/goggles, moving directly between COVID-positive and COVID-negative rooms. The Dietary Manager (DM) entered a room posted with droplet precautions multiple times wearing only a KN95 mask, delivering and removing meal trays and cups for COVID-positive residents, and did not consistently perform hand hygiene upon exiting the room. The report details that an Admission Coordinator (AC) delivered a meal tray to a COVID-positive resident while wearing only a surgical mask and no gown, gloves, or eye protection, despite droplet precaution signage on the door. After exiting the room, the AC handled cups and used the hallway ice chest and scoop without first sanitizing her hands, then returned the cups to nursing staff. Surveyors also observed that PPE supply carts for several COVID-positive residents lacked required items such as N95 masks, gloves, and face shields/goggles. During the same outbreak period, an LVN entered a COVID-positive resident’s room wearing only a KN95 mask and stated that a KN95 mask was appropriate and that face shields or goggles were optional, and later was observed in another COVID-positive resident’s room wearing only a surgical mask with no gown, gloves, or eye protection while assisting the resident. Additional deficiencies included improper glove use and hand hygiene during clinical care. An LVN checked a resident’s blood sugar and then administered enteral tube medications without changing gloves or performing hand hygiene in between tasks. Interviews with staff, including LVNs, the AC, the DM, the Infection Preventionist (ADON), the DON, and the Regional Administrator, confirmed inconsistent understanding and implementation of PPE requirements for COVID-positive rooms, confusion about the difference between N95 and KN95 masks, and uncertainty about who was responsible for stocking PPE carts. Facility policies reviewed by surveyors specified that N95 masks with goggles or face shields, gowns, and gloves were required for COVID isolation rooms, and that hand hygiene was required after removing gloves, after handling soiled items, and before handling food or medications. Despite these policies, observations and interviews showed that staff did not consistently adhere to these infection control requirements during the COVID-19 outbreak. The report also notes that several residents involved had significant medical conditions and were on isolation precautions for active infectious disease, including COVID-19. These residents included individuals with chronic obstructive pulmonary disease, Non-Hodgkin lymphoma, laryngeal cancer, cerebral palsy, prior COVID-19, neutropenia, fractures, and stroke-related hemiplegia/hemiparesis. Many had severe cognitive impairment as indicated by low BIMS scores, and some required extensive assistance with activities of daily living or had feeding tubes. Facility records, including care plans, MDS assessments, and physician orders, documented that these residents were COVID-positive and on droplet/respiratory isolation, with interventions specifying use of PPE and infection control practices. However, surveyor observations and staff interviews demonstrated that these ordered precautions and facility policies were not consistently implemented in practice.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to personal and medical records to a resident’s legal representative after a valid request. The resident was an elderly female with Alzheimer’s disease who had been admitted with that diagnosis and later had an unplanned discharge with anticipation of return. Her attorney, acting as her legal representative, sent a written request for records, including all correspondence with the Texas Health and Human Services Commission related to the resident’s Medicaid nursing facility benefits for the prior two years, as well as the daily plan of care, nursing logs, medication logs, incident reports, and any emails, letters, and notes related to the resident. A HIPAA Authorization to Disclose Protected Health Information, signed by the resident’s legal representative, authorized the attorney’s office to receive any and all information concerning treatment or services rendered to the resident. Despite this, the attorney reported during interview that she had still not received the requested records months after the initial request, and she confirmed with Medical Records and the Administrator that the request had been received. Interviews and document review showed that the facility did not follow an effective process to ensure the request was fulfilled within regulatory timeframes. The Medical Records staff stated that attorney requests were sent to the corporate office and the facility’s attorney and were not handled at the facility level; she acknowledged awareness of the request and said it had been sent to the Administrator before he went on leave. The facility’s attorney/Chief Operating Officer later stated that the record request had been “overlooked and missed.” The Regional Administrator reported that the records request had been sent directly to the attorney rather than to the designated medical records request email and that there was no process in place to monitor the request after it was forwarded. The facility’s Release of Information Protocol indicated that legal and personal requests should be sent to a specific Medical Records Request email for review and presentation to the facility’s attorney, but the monitoring and follow-through steps were not carried out, resulting in the resident’s legal representative not receiving the requested records as required.
Failure to Provide Timely and Proper Incontinent Care and Pericare, Increasing UTI Risk
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate incontinent and perineal care to a female resident who was incontinent of bowel and bladder. The resident, an older adult with heart failure, obesity, and hypothyroidism, had an annual MDS showing a BIMS score of 14, indicating no cognitive impairment, and required dependent assistance with ADLs. ADL documentation for January and February 2026 showed very low recorded frequencies of incontinent care on day and evening shifts. The resident reported she was typically cleaned only once per shift and stated that on two occasions in the month she went more than an entire day without being cleaned. She also reported that CNAs placed blankets under her to catch urine and keep the sheets dry, and that she had contacted the Ombudsman after feeling the Social Worker and DON were not resolving her concerns. During an observed episode of perineal care, two CNAs entered the resident’s room to perform care. One CNA washed her hands only before starting care and not again until leaving the room, while the other did not wash hands before beginning care. One CNA stated she did not have hand sanitizer and that the facility did not provide it, and proceeded with care as usual. When the resident’s brief was removed, it was completely saturated, urine leaked onto the sheets, and there was a strong ammonia odor. The CNA stated it was the first time she had touched the resident that day, and the resident stated it was the first time she had been changed since around 2:00 a.m., reporting soreness of her thighs, buttocks, and vagina from being wet for a prolonged period. The CNA noted that blankets under the resident had likely been placed by night shift. During the same care episode, the CNA changed gloves without washing hands and continued incontinent care. She wiped from the top of the buttocks toward the vagina four times using the same wipe, with BM noted on the wipe when discarded, contrary to the facility’s perineal care policy, which directs wiping from vagina toward anus for females and discarding the washcloth after each stroke. In a subsequent interview, the CNA acknowledged she had not performed pericare correctly, citing lack of hand sanitizer and recognizing that wiping from back to front could cause infection. She also stated there was not enough staff to keep all residents clean and dry. The DON stated that hand hygiene and proper wiping technique were expected to prevent introducing bacteria to the urinary tract and that there were two CNAs on the hall with no reason for unreasonable delays in care, while also acknowledging a facility-wide problem with documentation. The Administrator stated she expected perineal care to be done “by the book,” timely and with infection-prevention techniques, and indicated she was unaware of the resident’s care problems because no grievance had been written despite the resident’s complaints.
Failure to Prevent Accident Hazards During Resident Transportation
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents during transportation. Three residents experienced incidents related to unsafe transport practices. One resident, who was dependent on staff for transfers and used a wheelchair, reported falling to the floor of the facility van when the driver swerved to avoid another vehicle. The resident was not secured with a seatbelt, slid out of the wheelchair, and was assisted by dialysis clinic staff. The incident was not reported by the van driver or the resident to facility staff, and there was no documentation of the fall in the facility's records. Another resident complained about the van driver's unsafe and inattentive driving, stating that the driver was more focused on his drink than on the road. The administrator received this complaint and counseled the driver, but the unsafe driving behavior continued. A third resident, who was also dependent on staff for transfers and used a wheelchair, was not properly secured in the van. The van driver failed to attach one of the wheelchair hooks, causing the wheelchair to tip backward during transport. The resident sustained a skin tear and a bruise, complained of a headache, and was later sent to the emergency room for evaluation. The van driver did not notify facility staff or call emergency services at the time of the incident, instead continuing with the transport as planned. The van driver involved in these incidents had received periodic training on transportation safety and facility policies, which included instructions on securing residents and responding to emergencies. Despite this, the driver failed to follow established procedures, such as securing wheelchairs and reporting incidents. The facility's records indicate that the driver did not report falls or injuries as required, and interviews with staff and residents confirmed lapses in communication and adherence to safety protocols.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. Surveyors identified that the required program was either not established or not effectively carried out, as evidenced by the lack of documentation or observation of infection control practices. There were no specific details provided regarding individual residents, staff actions, or particular infection control breaches, but the absence of a program itself constituted the deficiency.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents, leading to their elopement. Resident #289, a male with severe cognitive impairment due to neurocognitive disorder with Lewy bodies and Parkinson's disease, eloped from the facility. Despite being a moderate elopement risk, he was allowed to sit outside unsupervised, which facilitated his departure. He was later found at a local restaurant, having crossed a busy road, and sustained minor injuries from a fall. The resident expressed confusion about his ability to leave the facility and demonstrated impulsive behavior, which was not adequately managed by the facility. Resident #290, a male with dementia and a history of violent behavior, was identified as a high elopement risk. He attempted to leave the facility multiple times, believing he was meeting a deceased family member. On one occasion, he fell outside the facility, sustaining minor injuries. Despite being on 15-minute checks, the facility's measures were insufficient to prevent his attempts to leave. Staff struggled to redirect him, and his persistent attempts to elope highlighted the inadequacy of the facility's supervision and risk management strategies. The facility's failure to provide adequate supervision and implement effective elopement prevention measures placed both residents at risk of harm. The incidents revealed lapses in monitoring and assessing residents' elopement risks, as well as a lack of timely intervention to prevent their unsupervised departure from the facility. These deficiencies were identified as posing an immediate jeopardy to resident safety, necessitating corrective actions to address the identified risks.
Incorrect Diagnoses Associated with Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for three residents were free from unnecessary medications due to incorrect diagnoses being associated with their medication orders. For Resident #33, the facility did not have the correct diagnosis for diabetes mellitus medications, instead associating them with a diagnosis of heart failure. This miscommunication could lead to misdiagnosing and inappropriate treatment. Interviews with the nursing staff revealed that the responsibility for entering the correct diagnosis with medication orders was not consistently managed, leading to potential confusion and treatment errors. Resident #65's medication orders were also incorrectly documented with a diagnosis of type 2 diabetes for medications that were intended to treat other conditions such as hypertension and pain. The medications included Acetaminophen with Codeine, Lisinopril, Metoprolol, Amlodipine, and Apixaban, all of which were incorrectly associated with diabetes. This misalignment of diagnoses and medications could result in inappropriate treatment and monitoring, as well as potential issues with coding and billing. Similarly, Resident #80's medication orders were associated with a diagnosis of acute kidney failure, which was not appropriate for the medications prescribed, including pain relievers and antihypertensives. The incorrect association of diagnoses with medications could hinder proper follow-ups, lab work, and monitoring, potentially leading to adverse drug reactions. Interviews with the nursing staff and administration highlighted a lack of clarity and oversight in ensuring that medications were linked to the correct diagnoses, which could have detrimental effects on resident care.
Failure to Adhere to Medication Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of antihypertensive medications. The resident, a 59-year-old female with diagnoses including cerebral infarction, hyperlipidemia, and hypertension, was administered medications such as Amlodipine, Carvedilol, Hydralazine, and Losartan despite her blood pressure and/or pulse being outside of the ordered parameters on multiple occasions. These medications were to be held if the resident's systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or pulse was less than 60. On specific dates, the resident received these medications even when her blood pressure readings were below the prescribed thresholds. For instance, on one occasion, Hydralazine was administered when the resident's blood pressure was recorded at 90/52 and 90/50, which was below the hold parameters. Similarly, Amlodipine, Losartan, and Carvedilol were administered when the resident's blood pressure was 103/68, which was also below the required threshold for administration. Interviews with facility staff, including an LVN and the Director of Nursing, revealed that the nursing staff was expected to follow the blood pressure parameters set by the physician. The Director of Nursing stated that if a resident's blood pressure was lower than the set parameters, the physician should be notified to decide whether to hold or administer the medication. However, there was no documentation of any phone calls to the physician regarding the resident's low blood pressure readings on the dates in question.
Menu and Portion Control Deficiencies
Penalty
Summary
The facility failed to ensure that the menus met the nutritional needs of residents and were followed as planned for two consecutive lunch meals. On December 2, 2024, the facility did not serve the posted lunch menu items, substituting breadsticks with sliced white bread and iced cinnamon raisin bars with chocolate chip cookies. On December 3, 2024, the cook did not follow the recipe for cheesy rice, using sliced cheese instead of shredded cheese, and served canned mushroom soup instead of homemade soup. Additionally, the facility did not use the appropriate serving sizes for various meal components, leading to inconsistencies in portion sizes. Interviews with residents and staff revealed dissatisfaction with the portion sizes and the menu not being followed. Resident #52 expressed concerns about small portion sizes and the inconsistency of having enough food for seconds. A grievance filed by a family member of Resident #63 also indicated that the menu was not being followed during mealtimes. Staff interviews highlighted that the kitchen sometimes ran out of food, and substitutions were made without proper documentation or notification to residents. The Dietary Manager and other staff members acknowledged the importance of following recipes and portion sizes to ensure residents' nutritional needs are met. They noted that not adhering to these guidelines could lead to weight loss and other health issues. The facility's policies on portion control, use of recipes, and menu adherence were not effectively implemented, as evidenced by the discrepancies observed during meal services.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. On December 2, 2024, it was noted that food stored in the kitchen refrigerator was not labeled or dated, including a bag of meat and an opened container of blueberry frozen muffin batter. Additionally, cookware in the pantry and main kitchen area had carbon build-up, and containers of cornmeal and sugar were not properly sealed, with cornmeal spilled on the pantry floor. Three white bins used for storing metal lids contained food particles, and the food steamer had a brown film and food particles at the bottom. On December 3, 2024, further observations revealed that the facility did not ensure food was temped before serving. Pureed chicken, ground chicken, canned soup, pureed tomatoes and okra, mashed potatoes, and chicken breast were served without checking their temperatures. The scooper fell into the food during plating, and the Dietary Manager did not practice proper hand hygiene, coughing on her arm and then plating a meal without washing her hands. The juice dispenser and vent were also found to be unclean, with an orange substance inside the handle and brown, fuzzy material on the vent. Interviews with staff, including the Dietary Manager and Director of Nursing, confirmed that the facility's practices did not align with their policies. The staff acknowledged the importance of labeling and dating food items, maintaining kitchen cleanliness, and ensuring food safety through proper temperature checks. The Administrator emphasized the need for food to be served at safe temperatures and for the kitchen to be clean to prevent foodborne illnesses and cross-contamination.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for several residents and a family member. Multiple residents reported that their meals were often served cold, bland, and either overcooked or undercooked. Specific complaints included cold breakfasts and dinners, repetitive meal options, and unappetizing food presentation. A family member also noted that the food did not look appetizing and was inconsistently cooked. During a test meal, surveyors and the Dietary Manager found the mashed potatoes to be bland and the food lukewarm. Interviews with staff revealed that the cook was responsible for preparing warm and flavorful meals, but there were issues with the food's taste and temperature. The Dietary Manager acknowledged that if recipes were followed, the food should be flavorful, and the Director of Nursing noted that recent menu changes had not been well-received by residents. The Administrator emphasized the importance of serving meals that residents would want to eat, and the facility's policy indicated that meals should be nourishing and palatable. The deficiency could potentially lead to weight loss and diminished quality of life for residents.
Infection Control Deficiency Due to Improper Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper glove use and hand hygiene by staff members during resident care. On the specified date, two CNAs, while providing catheter care to a resident with multiple health issues including metabolic encephalopathy, urinary tract infection, and pressure ulcers, did not change their gloves or perform hand hygiene after completing the care. This oversight occurred despite the resident's care plan indicating the need for enhanced barrier precautions due to the presence of a multi-drug resistant organism and other infections. In another instance, a CNA assisting with incontinent care for a resident with Alzheimer's disease and other health conditions failed to change gloves and perform hand hygiene after cleaning the resident and before applying skin protectant cream. The CNA also did not perform hand hygiene after removing gloves and before putting on new ones. This lapse in protocol was observed by a WCLVN, who noted the potential for cross-contamination and infection risk due to improper glove use and lack of hand hygiene. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed the expectation for staff to perform hand hygiene before and after glove use to prevent cross-contamination. The facility's policies on hand hygiene and perineal care emphasize the importance of these practices in reducing infection spread. However, the observed actions of the CNAs did not align with these policies, leading to the identified deficiencies in infection control practices.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #35, had a call light within reach, which is a reasonable accommodation of the resident's needs and preferences. Resident #35, an elderly female with severe impaired cognition and a high fall risk, was observed multiple times over several days with her call light either hanging in the headboard of her bed or on the floor beside her bed, making it inaccessible. This was despite her care plan indicating that she required substantial assistance with activities of daily living and was encouraged to call for assistance to promote her safety. Interviews with various staff members, including CNAs, an LVN, the ADON, the DON, and the ADM, revealed a consensus that all staff members were responsible for ensuring that call lights were accessible to residents. However, it was noted that Resident #35's call light was not consistently within her reach, which could prevent her from alerting staff to her needs. The facility's Call Lights Answering Policy also emphasized the importance of ensuring call lights are within residents' reach, yet this was not adhered to in the case of Resident #35.
Failure to Update Survey Results Book
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was easily accessible to residents, family members, and legal representatives. During a record review, it was found that the survey results book in the lobby contained outdated information, with the most recent state visit result dated 12/01/23, despite a more recent survey having been conducted with an exit date of 08/15/24. This oversight was confirmed during interviews with the RNC and the Administrator, who acknowledged the responsibility for maintaining the survey results book. The RNC admitted there was no policy in place for updating the survey results book and was unsure of how many visits were missed. The Administrator confirmed that it was his responsibility to ensure the survey results books were up to date. The lack of updated survey results could potentially prevent residents and their families from being aware of past and current violation findings from state surveys and investigations conducted in the facility.
Failure to Conduct PASRR Review for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident with a mental health disorder received an accurate Preadmission Screening and Resident Review (PASRR) following a new diagnosis of major depressive disorder. The resident, a 64-year-old female, was diagnosed with major depressive disorder on 05/13/24, but the facility did not refer her for a PASRR review. This oversight was discovered during a record review and interviews, revealing that the resident had not received the necessary PASRR evaluation, individualized care, or specialized services to address her mental health needs. Interviews with facility staff, including the MDS LPN and the Director of Nursing, highlighted a lack of knowledge and coordination regarding the PASRR process. The MDS LPN acknowledged that a new PASRR Level 1 should have been submitted following the resident's new mental illness diagnosis, but it was not completed. The Director of Nursing admitted to limited knowledge about the PASRR process, and the Administrator expressed reliance on the local mental authority to submit a new PASRR Level 1. The facility's PASRR Pre-Admission Process Flow policy did not adequately address updating the PASRR Level 1 after a new mental illness diagnosis, contributing to the deficiency.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary assistance to maintain good nutrition, grooming, personal, and oral hygiene. This deficiency was observed in a resident with a history of cerebral infarction, hemiplegia, and hemiparesis, who was dependent on staff for transfers from bed to chair. The resident expressed distress over being confined to bed for an entire month, during which she ate, slept, and used the bathroom in bed, indicating a lack of assistance in getting out of bed. The resident's care plan required staff to provide appropriate assistance to promote her safety, yet multiple entries in the ADL function report indicated that transfers did not occur on several occasions throughout November. Interviews with staff, including CNAs and the Director of Nursing, revealed that the resident should have been assisted out of bed upon request, and that failure to do so could lead to negative outcomes such as depression, low self-esteem, and skin breakdown. Despite the resident's requests and the facility's policy, the necessary assistance was not consistently provided. The Director of Nursing acknowledged that the resident preferred a wheelchair over a Geri-chair and that staff were instructed to assist her with a partner due to previous abuse allegations. However, the resident's needs were not met consistently, as evidenced by her prolonged confinement to bed and the lack of documented transfers. The facility's policy on ADL care and transfer techniques was not adhered to, resulting in the resident's unmet needs and emotional distress.
Failure to Ensure Correct Pressure-Relieving Mattress Settings
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards to prevent pressure ulcers. The resident, a 76-year-old female, had a history of metabolic encephalopathy, urinary tract infection, Type II diabetes, and severe pressure ulcers on the right and left buttocks. Despite being on a turning/repositioning program and receiving pressure ulcer care, the resident's pressure-relieving mattress was not set correctly according to her weight, which was 155 pounds, but the mattress was set for 250 pounds. Observations over several days confirmed that the mattress settings were consistently incorrect, which could contribute to the development of avoidable pressure ulcers. Interviews with various staff members, including the Wound Care LVN, Resident Service, Director of Nursing, and the Administrator, revealed a lack of clarity and responsibility regarding who was accountable for ensuring the correct settings on the pressure-relieving mattress. Each staff member had different understandings of their roles, leading to the oversight of the incorrect mattress settings. The facility's policies on support surfaces and wound care emphasized the importance of using pressure redistribution devices according to the manufacturer's instructions to prevent skin breakdown. However, the failure to adhere to these guidelines and ensure the correct mattress settings placed the resident at risk for further skin issues. The staff's lack of awareness and communication about the responsibility for mattress settings contributed to this deficiency.
Inadequate Perineal and Catheter Care for Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents, leading to potential risks of urinary tract infections. Resident #65, a 76-year-old female with multiple diagnoses including metabolic encephalopathy, urinary tract infection, and pressure ulcers, was observed receiving inadequate catheter care. During the procedure, CNA E and CNA L did not follow the facility's policy for catheter care, as they failed to properly clean the resident's perineal area and catheter tubing. Additionally, when the disposable wipes fell on the floor, they were picked up and used again without replacing them, compromising infection control measures. Resident #63, an 84-year-old female with Alzheimer's disease and other conditions, was found with feces on her thigh and brown stains on her brief, indicating improper cleaning during previous incontinence care. During a skin assessment, WCLVN G noted that CNA F wiped towards the resident's vagina instead of away, which is against the facility's perineal care policy. This improper technique could lead to skin breakdown and increase the risk of infection. Interviews with the Director of Nursing and the Administrator revealed that the staff did not adhere to the expected standards of care, including cleaning from front to back and ensuring residents were clean after incontinence care. The facility's Perineal Care policy outlines specific procedures to prevent skin breakdown and infection, which were not followed in these instances, placing the residents at risk for urinary tract infections.
Failure to Follow Dietary Recommendations and Monitor Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #81, who was on enteral feeding due to dysphagia following a cerebral infarction. The dietician recommended a change in the resident's tube feeding formula to Glucerna 1.5 at 60 ml/hr starting in September, but the facility continued to administer Glucerna 1.2. Additionally, the dietician advised weekly weight monitoring beginning in November, which was not implemented. These oversights were compounded by a lack of follow-up on a significant 9.12% weight loss over three months. Observations and interviews revealed that the facility's staff, including RN A, were unaware of the dietician's recommendations and the resident's weight loss until it was brought to their attention during the survey. The RN acknowledged that the dietary recommendations were not followed and that the resident's weight loss was not addressed. The facility's process for handling dietary recommendations was unclear, with staff unsure of who was responsible for ensuring these recommendations were acted upon. The dietician had communicated her recommendations via email to the DON, ADON, and other relevant staff, but these were not acted upon. Interviews with the DON, ADON, and other staff members highlighted a breakdown in communication and responsibility. The DON admitted to missing the dietician's emails and acknowledged that the previous ADON had not been managing the dietary recommendations effectively. The ADON, who was new to the facility, was not aware of the process for handling dietary recommendations and weight loss, leading to a failure in addressing the resident's nutritional needs. The facility's policies on enteral nutrition and weight monitoring did not adequately address the need for following dietary recommendations or ensuring physician orders were updated accordingly.
Deficiencies in Psychotropic Medication Management and Monitoring
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary psychotropic drugs. For one resident, there was no appropriate diagnosis entered for the prescribed Escitalopram, which is commonly used to treat depression and anxiety. Instead, the medication was incorrectly associated with a diagnosis of Type 2 diabetes. This discrepancy was noted in the resident's medication administration records, where the resident received 30 doses of Escitalopram without a proper diagnosis to justify its use. Another resident was prescribed multiple psychotropic medications, including Venlafaxine, Divalproex, and Mirtazapine, for major depressive disorder. However, there was a lack of behavior monitoring to assess the effectiveness of these medications. The behavior monitoring log for this resident did not reflect any data, despite the requirement for nurses to document behaviors every shift. Interviews with nursing staff revealed that behavior monitoring was supposed to be documented in the facility's electronic charting system, but this was not done for the resident in question. The Director of Nursing and other staff acknowledged the importance of having correct diagnoses for medications and the necessity of behavior monitoring to evaluate treatment efficacy. However, the facility's failure to document behavior monitoring and ensure appropriate diagnoses for psychotropic medications led to deficiencies in the care provided to these residents. The facility's policy on psychotropic drug use emphasized the need for supporting diagnoses and documentation of non-drug interventions, which were not adequately followed in these cases.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate the food preferences of a resident, identified as Resident #77, who expressed a desire for specific breakfast items, including boiled eggs, cereal, toast, and milk. Despite the resident's clear communication of these preferences, the facility did not provide the requested items on multiple occasions. On the mornings of December 3rd, 4th, and 5th, the resident did not receive boiled eggs as requested, and on one occasion, scrambled eggs were listed on the meal ticket but were not provided. This lack of accommodation was confirmed through interviews with the resident and observations of the meal trays. The deficiency was further compounded by the facility's failure to obtain the resident's meal choices for each meal. Interviews with staff, including CNAs and the Dietary Manager, revealed that the 2nd shift CNAs were responsible for collecting meal preferences but were not consistently doing so. This resulted in residents receiving the default posted meal instead of their preferred choices. The Dietary Manager acknowledged the issue and noted that it had been previously addressed with nursing administration but had not been sustained. The Director of Nursing and the Administrator both recognized the importance of honoring residents' food preferences, citing potential impacts on residents' quality of life and caloric intake. The facility's policies indicated that trays should be checked for special requests and that meals should be tailored to residents' nutritional needs and preferences. However, these policies were not effectively implemented, leading to the deficiency in accommodating Resident #77's meal preferences.
Resident Exposed Due to CNA's Inaction
Penalty
Summary
The facility failed to treat a resident with respect and dignity, as required by resident rights regulations. The incident involved a resident with dementia and anxiety disorder, who had a moderate cognitive impairment. The resident reported that a CNA left her exposed to the hallway after she requested the CNA to leave her room. The CNA admitted to leaving the resident's sheet and blanket pulled back, leaving the resident exposed, and did not close the door. The resident expressed feeling upset and worried about being seen by others. Interviews with facility staff, including the Activity Director, ADON, DON, and Administrator, confirmed the incident and the expectation that the resident should have been covered and the door closed to ensure privacy. The facility's policy on perineal care emphasized the importance of draping residents with linens to provide privacy. The failure to adhere to these policies and procedures resulted in a deficiency related to the resident's right to dignity and privacy.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which resulted in deficiencies in their care. Resident #63, an 84-year-old female with Alzheimer's disease, muscle weakness, and pain, was observed without a pillow in her wheelchair on multiple occasions, despite her care plan intervention requiring it for comfort and to prevent skin breakdown. The absence of the pillow was noted during observations on two consecutive days, and it was acknowledged that the resident often wiggled in her chair, which necessitated the use of a pillow for proper positioning. Resident #80, a 59-year-old female with cerebral infarction, hemiplegia, and dysphagia, had a care plan intervention to monitor her oral intake due to her altered nutritional status. However, there was a lack of documentation of her meal intake throughout November 2024, with numerous instances of missing records for breakfast, lunch, and dinner. This failure to document her intake could hinder the facility's ability to monitor her nutritional status and address any potential weight loss concerns. Interviews with facility staff, including an LVN, CNA, and the Director of Nursing, revealed that the CNAs were responsible for documenting meal intakes, and the LVNs were to ensure this documentation was completed. The staff acknowledged the importance of following care plan interventions and the role of documentation in tracking residents' nutritional status and preventing issues such as weight loss. The facility's policies on care planning and meal intake documentation emphasized the need for individualized care and monitoring, which were not adhered to in these cases.
Failure in Accurate Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, specifically in the administration of Hydralazine, a medication used to treat high blood pressure. The resident, a 59-year-old female with a history of cerebral infarction and hypertension, was supposed to have her blood pressure and pulse checked before each administration of the medication. However, the records showed repeated identical readings for blood pressure and pulse on multiple occasions, suggesting that the checks were not performed accurately or at all. This was confirmed through interviews with the LVN and the Director of Nursing, who both acknowledged that the same readings could indicate falsification and that proper monitoring was essential to prevent potential harm to the resident. The resident's care plan required monitoring of blood pressure every shift, and the medication administration record specified holding the medication if certain blood pressure or pulse thresholds were not met. Despite these requirements, the facility's staff failed to ensure accurate and new readings were taken before administering the medication. Interviews with the LVN and the Administrator highlighted the importance of following physician orders and the potential risks of not doing so, such as the resident experiencing adverse effects if the medication was administered when not needed.
Failure to Update Care Plans Following Significant Changes
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for four residents were reviewed and revised by the interdisciplinary team following significant changes in their conditions. Resident #18 exhibited physically aggressive behavior towards another resident, but the care plan did not include any interventions for managing such behavior. Despite the incident being documented in the nurse's notes, the care plan remained unchanged, leaving staff without guidance on how to address potential future occurrences. Resident #6 experienced a fall resulting in a major injury, specifically a hip fracture, yet the care plan was not updated to include interventions for managing the fracture or preventing further falls. Although the fall was discussed in clinical meetings, the necessary updates to the care plan were not made, indicating a lapse in communication and follow-through. Similarly, Resident #8's care plan was not revised to include interventions such as a scoop mattress and fall mat after a fall that resulted in a fractured nose and head injury, despite these interventions being noted in the incident report. Resident #10 also suffered a fall with a closed head injury, but the care plan did not reflect the use of a fall mat and pommel cushion, which were observed to be in place during a later inspection. The MDS Coordinator and DON acknowledged the importance of updating care plans promptly to ensure staff are informed of current interventions, but the failure to do so left staff without critical information needed to prevent further incidents. The facility's policy requires care plans to be revised as residents' conditions change, but this was not adhered to in these cases.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor a resident's right to self-determination and to make healthcare decisions for herself. This deficiency involved a resident who was not allowed to go to the hospital when she requested it. The resident, who had a BIMS score indicating no cognitive impairment, was on dialysis and had complex medical conditions including peripheral vascular disease, sepsis, and diabetes mellitus type II. On the day of the incident, the resident felt unwell and experienced confusion and hallucinations, which she recognized as potential signs of a medical issue due to her dialysis treatment. Despite her request to be sent to the hospital, the agency nurse, LVN M, refused to call an ambulance, stating that the resident was medically stable and that it would be against medical advice to send her out. The resident's family attempted to intervene by calling the facility multiple times, but the nurse did not comply with their requests and even hung up on them. The nurse checked the resident's vital signs and consulted with an MD, who reportedly advised against sending the resident to the hospital, although no documentation of this consultation or the vital signs was recorded. Eventually, a family member came to the facility and called an ambulance himself. The facility's Director of Nursing and Administrator were aware of the incident, and the nurse was subsequently removed from the schedule.
Failure to Protect Residents from Abuse by CNAs
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by incidents involving two certified nursing assistants (CNAs). In the first incident, a CNA was reported to have shaken a resident's wheelchair while providing incontinent care. The resident, who had severe cognitive impairment due to dementia, was unable to recall the event. The incident was reported by another CNA who witnessed the event and noted that the involved CNA was visibly upset during the care process. In the second incident, another CNA forcefully pushed a resident's wheelchair across a hallway. The resident, who had cerebral palsy and severe cognitive impairment, was being combative at the time. A licensed vocational nurse (LVN) witnessed the incident and intervened, noting that the resident could have been injured. The CNA involved did not deny the action but stated she was reacting to being hit by the resident. Both incidents were documented in the facility's Potential Incident Report (PIR) and involved the suspension and eventual termination of the CNAs involved. The facility's abuse policy emphasizes the right of residents to be free from abuse by anyone, including facility staff. The incidents highlight a failure to adhere to this policy, resulting in potential harm to the residents involved.
Inadequate Discharge Planning Leads to Unsafe Transition
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, leading to an unsafe transition to post-discharge care. The resident, a female with peripheral vascular disease, sepsis, and diabetes mellitus type II, was admitted to the facility and required substantial assistance for daily activities. Despite planning to return home after discharge, there were no care plans or discharge instructions documented in her electronic health record. The resident reported receiving no written or oral instructions on her medication or treatment regimen before discharge, and upon returning home, she lacked the necessary durable medical equipment (DME) such as a hospital bed and mechanical lift. Interviews revealed that the social services department had not communicated the resident's early discharge to the home health or DME providers, resulting in a lack of essential support at home. The resident's family was able to assist with some tasks, but the absence of DME and medication instructions led to her readmission to the hospital for hypokalemia. The facility's discharge policy required the provision of home health and DME for a safe living environment post-discharge, which was not adhered to in this case.
Inadequate Supervision Leads to Resident's Fall
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with severe cognitive impairment and a high risk of elopement. The resident, who had a history of dementia, atrial fibrillation, and diabetes mellitus type II, was admitted with a high elopement risk and required partial to moderate assistance with activities of daily living. Despite being identified as a high elopement risk, the resident managed to exit the facility and fell from his wheelchair, sustaining a hematoma and abrasion to his head. The incident occurred when staff were occupied with meal service, and the resident was not adequately supervised. Interviews with staff revealed that the resident frequently attempted to find exits and was difficult to redirect due to his dementia. Staff were aware of his elopement risk and attempted to monitor him closely, but during busy times such as meal service, it was challenging to maintain constant supervision. The Director of Nursing acknowledged the resident's high risk of elopement and the facility's inability to meet his needs, leading to his discharge to a secured unit. The facility's fall prevention policy emphasized evaluating residents for fall risk and developing interventions, but these measures were insufficient in preventing the resident's accident.
Failure to Administer IV Antibiotics Timely
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of IV antibiotics. A resident, who was admitted with diagnoses including peripheral vascular disease, sepsis, and diabetes mellitus type II, was supposed to continue receiving vancomycin and meropenem as per discharge instructions from an acute hospital. However, the facility did not initiate the meropenem treatment until three days after the prescribed start date. This delay occurred because the nurse responsible for the resident's admission noted the need for clarification on the antibiotic order but did not follow up, and the oversight was not caught until a chart audit was conducted. The delay in administering meropenem was attributed to the discharge orders being overlooked, and the lack of a care plan for IV antibiotics in the resident's electronic health record. The resident continued to receive vancomycin during dialysis, and no acute issues were observed by the Director of Nursing. The nurse practitioner involved stated that the missed doses did not result in harm to the resident, as there were no signs of physical decline. The facility's policy on administering medications emphasizes the importance of timely and accurate medication administration, which was not adhered to in this instance.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
