Rockwall Nursing Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Rockwall, Texas.
- Location
- 206 Storrs, Rockwall, Texas 75087
- CMS Provider Number
- 675402
- Inspections on file
- 45
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Rockwall Nursing Care Center during CMS and state inspections, most recent first.
The facility failed to keep call lights within reach for three cognitively impaired residents with dementia, Alzheimer’s disease, anxiety, mobility limitations, and extensive ADL assistance needs. Observations showed one resident’s call light stored in a closed nightstand drawer blocked by a bedside table, another resident’s call bell lying across a nightstand out of reach, and a third resident’s call bell on a nightstand on the floor, also out of reach. Each resident’s care plan required the call light to be placed within reach and its use encouraged. Staff, including CNAs, LVNs, the DON, and the Administrator, acknowledged that facility policy mandates call bells be accessible to all residents at all times to allow timely assistance, yet the observed call light placements did not follow these requirements.
Surveyors found that two residents with Alzheimer’s disease, severe cognitive impairment, and dependence for ADLs had visibly stained privacy curtains, one with large brown stains and one with red stains, despite staff and leadership (including CNAs, LVNs, the DON, and the Administrator) stating that all staff were responsible for identifying and reporting housekeeping needs during rounds to maintain a clean, homelike environment in accordance with the facility’s infection control program.
Two residents with severe cognitive impairment and significant ADL dependence received perineal care from an LVN who did not follow infection control practices, including failing to change gloves between dirty and clean tasks, not performing hand hygiene between glove changes, and moving a bedside table between rooms without sanitizing it or changing the linen covering, contrary to facility policy and staff training.
The facility failed to maintain an effective pest control program on a secure male hall, where gnats were observed in two residents’ rooms and had reportedly been an ongoing issue. An LVN, a CNA, and housekeeping staff confirmed the persistent presence of gnats on the hall and in resident living areas, and leadership, including the DON and administrator, acknowledged awareness of the problem. Pest control service records over several months showed multiple visits treating for other pests but not specifically for gnats, and internal reports from the hall documented staff observations of water bugs and gnats that were not addressed, contrary to the facility’s insect and rodent control policy.
A resident with cervical spina bifida, paraplegia, and an indwelling urinary catheter was care-planned for enhanced barrier precautions, requiring staff to wear a gown and gloves for high-contact care such as incontinence care. Despite clear signage at the room entrance and available PPE, a CNA provided incontinence care wearing only gloves and later stated she believed gowns were needed only for certain infections or infected wounds. The resident reported that some staff used both gown and gloves during incontinence care while others did not, and nursing leadership confirmed that enhanced barrier precautions and the facility’s policy required gown and glove use for residents with indwelling devices during such care.
Two residents with severe cognitive impairments were involved in an incident where one slapped the other in the face. The resident who committed the act had a history of behavioral symptoms and poor impulse control, and the event was indirectly witnessed by staff after a noise and a report from another resident. Both residents were unable to recall the incident due to cognitive deficits, and the facility failed to prevent this occurrence despite documented behavioral risks.
Two residents with severe cognitive impairment and behavioral issues were involved in an incident where one slapped the other, which was not directly witnessed by staff but reported by a CNA and another resident. The affected resident could not recall the event due to cognitive deficits. The facility did not effectively implement its abuse prevention policies, resulting in a failure to prevent and immediately identify the abuse.
A CNA operated a mechanical lift alone to transfer a resident with obesity and muscle weakness, contrary to the care plan and facility policy requiring two staff. This resulted in the lift collapsing and the resident sustaining five fractured ribs. Staff interviews and documentation confirmed that two-person assistance was required for all mechanical lift transfers.
Two residents with significant physical and cognitive impairments were found without accessible call lights, despite care plans and staff expectations requiring call lights to be within reach. Staff interviews confirmed the importance of call light accessibility and routine checks, but observations showed that both residents' call lights were not accessible at the time of the survey.
Three residents who required respiratory care had their breathing devices, such as nebulizer masks, nasal cannulas, and inhalers, improperly stored when not in use, including being left unbagged on furniture, on the floor, or inside a nightstand. Nursing staff and leadership confirmed that these devices should be bagged to prevent infection, in accordance with facility policy.
Three residents with significant cognitive and physical impairments were found to have call lights placed out of reach, despite care plans requiring accessibility due to their high risk for falls and need for assistance. Staff interviews confirmed the expectation to keep call lights accessible, but lapses occurred during care, and no specific facility policy addressed call light placement.
The facility failed to maintain safe wheelchair conditions for four residents, leading to cracked armrests with exposed foam. Despite routine inspections, there was no documentation of repair requests for these wheelchairs. Staff interviews revealed inconsistencies in the reporting and repair process, indicating a lack of clear procedures and communication.
The facility's kitchen failed to meet food service safety standards, with issues such as unlabeled and undated food items, expired whipping cream, and improperly sealed open food in refrigerators. Interviews with the DM and DC confirmed expectations for proper labeling and storage, emphasizing risks of foodborne illness and allergic reactions. Observations and policy reviews highlighted the need for adherence to food safety protocols.
The facility failed to maintain a safe and functional environment, with deficiencies found in two resident rooms and a hallway. A resident's bathroom had a loose grab bar and exposed flooring, while another resident's sink had no running water. In the secure unit hallway, a handrail was missing endcaps, exposing sharp edges. Staff interviews revealed a lack of awareness and communication regarding these issues, with no reports found in maintenance logs or the new phone app.
The facility failed to protect resident confidentiality when an LVN left a computer unlocked and unattended on a medication cart, displaying resident medications. This occurred on the female locked unit while the LVN assisted residents, leaving the computer exposed to unauthorized access. The LVN acknowledged the need to lock the computer but underestimated the risk. Facility policy requires resident information to be kept confidential.
A resident with Alzheimer's and a history of falls was observed walking with improperly worn shoes, increasing fall risk. Despite a care plan intervention to ensure proper footwear, the resident often dressed herself incorrectly, and staff only intervened if allowed. The facility's policy emphasized the importance of proper footwear to prevent falls.
A medication cart was found unlocked and unattended in a facility, making medications accessible to residents and staff. LVN A, who was responsible for the cart, acknowledged the oversight but did not believe residents would tamper with it. The facility's policy requires carts to be locked when not in use.
A resident with severe cognitive impairment and a history of falls was left unsupervised in the dining room, resulting in a fall from his wheelchair and a bilateral subdural hematoma. Despite having a care plan that identified him as a fall risk, the facility failed to provide adequate supervision and interventions, leading to multiple falls throughout the year.
A facility failed to ensure a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. The resident, with diagnoses including dementia and acute kidney failure, had a care plan indicating a risk for multiple falls. The last care plan conference was held several months prior, and the subsequent quarterly meeting was not conducted. The Social Worker, responsible for scheduling these meetings, admitted to overlooking it, and the Administrator confirmed there was no reason for the oversight.
A resident with severe cognitive impairment and frequent incontinence did not receive a urine analysis (UA) as ordered by a physician due to multiple failed collection attempts and lack of communication with the nurse practitioner. The UA was canceled after three failed attempts, and the facility lacked specific policies for handling such situations. The resident was later diagnosed with a UTI during a hospital visit.
The facility failed to treat two residents with respect and dignity. An LVN yelled and slammed her hand on a table to redirect a cognitively impaired resident, while another resident reported being spoken to in a demeaning manner and often ignored by staff. The administrator confirmed that such actions could violate resident rights.
The facility failed to follow its smoking safety policies, resulting in a resident with severe cognitive impairments being left unsupervised while smoking. Miscommunication and misunderstanding among staff led to the resident being without direct supervision, contrary to the facility's smoking policy.
The facility failed to post daily nurse staffing information, leaving outdated information from April. The ADON admitted responsibility and acknowledged the oversight, which could prevent residents from accessing current staffing data and facility census information.
Failure to Keep Call Lights Within Reach for Multiple Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were within reach, as required by resident rights and facility policy. For Resident #3, a male with unspecified dementia with agitation, severe cognitive impairment (BIMS score of 3), impaired range of motion in both upper and lower extremities, and extensive assistance needs for all ADLs, the care plan directed staff to keep the call light within reach and encourage its use. During observation, this resident was in bed, awake, and not interviewable, with the call light found inside a closed nightstand drawer, blocked by the bedside table and out of reach. Resident #4, a female with Alzheimer’s disease, anxiety disorder, severe cognitive impairment (BIMS score of 3), extensive assistance needs for all ADLs, limited physical mobility, and impaired visual function, also had a care plan intervention to place the call light within reach and encourage its use. Observation showed her call bell lying across the nightstand and out of her reach. Staff, including an LVN, stated that per facility policy, call bells must be within reach of each resident to enable them to call for assistance when needed and to avoid delays in providing care. Resident #1, a male with dementia, severe cognitive impairment (BIMS score of 6), bilateral lower extremity weakness, and partial to moderate assistance needs for all ADLs, had a care plan noting risk for multiple falls, impaired cognitive function, and the need for timely meeting of needs. Observation revealed his call bell lying on the nightstand on the floor, out of his reach. Multiple staff members, including CNAs, LVNs, the DON, and the Administrator, confirmed that facility policy requires call bells to be within reach of all residents at all times, and that all staff are responsible for ensuring call bells are accessible before leaving the room to prevent delays in care and emergencies. Despite this, the observed placement of call lights for these three residents did not comply with their care plans or facility policy.
Failure to Maintain Clean and Sanitary Privacy Curtains for Two Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain clean and sanitary privacy curtains for two residents. For one resident, an older female with Alzheimer’s disease, anxiety disorder, severe cognitive impairment (BIMS score of 3), and extensive assistance needs for all ADLs, observation showed her privacy curtain had several large brown stains. Her care plan documented risks including falls, dependence on staff for emotional, intellectual, physical, and social needs, ADL self-care deficits, limited physical mobility, and impaired visual function, with instructions to keep her call light within reach and encourage its use. Despite staff statements that everyone was responsible for maintaining a homelike environment and reporting cleaning needs during rounds, the stained curtain remained in place. For another resident, an older male with Alzheimer’s disease, major depressive disorder, severe cognitive impairment (BIMS score of 5), bilateral lower extremity weakness, and dependence to substantial/maximal assistance for all ADLs, observation revealed his privacy curtain had red stains. His care plan noted risk for falls, impaired cognitive function, and ADL self-care performance deficits. Multiple staff members, including a CNA, LVNs, the DON, and the Administrator, stated that all staff shared responsibility for identifying and reporting housekeeping needs through regular rounds to ensure a clean, homelike environment. However, the presence of visibly stained privacy curtains for these two residents demonstrated that housekeeping and maintenance services were not effectively implemented to maintain a sanitary, orderly, and comfortable interior, contrary to the facility’s infection control plan overview, which required a safe, sanitary, and comfortable environment.
Failure to Follow Hand Hygiene and Equipment Sanitization During Perineal Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to incontinence and perineal care for two residents. Resident #1 was an older male with dementia, severe cognitive impairment (BIMS score of 6), bilateral lower extremity weakness, and a need for partial to moderate assistance with all ADLs. During observation of perineal care for this resident, LVN A cleaned the resident’s soiled perineal area and then applied cream to the perineal area without changing gloves between the dirty and clean tasks. LVN A also moved a bedside table from Resident #1’s room to another resident’s room without sanitizing the table or changing the covering linen. Resident #2 was an older male with Alzheimer’s disease, severe cognitive impairment (BIMS score of 5), bilateral lower extremity weakness, and dependence to substantial/maximal assistance for all ADLs. During observation of perineal care for this resident, LVN A applied cream to the perineal area, removed gloves, donned clean gloves without performing hand hygiene, applied cream to the groin area, then again removed gloves and donned clean gloves without sanitizing hands between glove changes. Interviews with LVN A, CNA A, the DON, and the Administrator confirmed that facility policy and staff training required changing gloves when moving from dirty to clean tasks, performing hand hygiene after glove removal and before donning clean gloves, and sanitizing shared equipment such as bedside tables between resident rooms, which did not occur during the observed care.
Failure to Maintain Effective Pest Control on Secure Male Hall
Penalty
Summary
The facility failed to maintain an effective pest control program to keep Hall 300, a male secure unit, and two resident rooms free of pests, specifically gnats. On the survey date, gnats were directly observed in two residents’ rooms on Hall 300. An LVN and a CNA confirmed the presence of gnats in both rooms and reported that pest control had been called, with the last pest control visit occurring earlier in the month. The LVN stated that gnats were an issue and had been reported to the administrator sometime the previous week, and acknowledged that gnats on resident food could cause infection. The CNA reported that gnats had been present in Hall 300 for a while and that she had reported their presence to the LVN. A housekeeper reported that she had notified the housekeeping supervisor about a persistent gnat problem and stated that gnats had been a problem since she began working at the facility about a year earlier, despite monthly pest control visits. The DON acknowledged awareness of the gnats and stated they could bite residents, spread infection, and were a dignity issue. The administrator also acknowledged that gnats were an ongoing issue. Review of pest control service reports for the prior seven months showed nine visits during which the company treated for other pests, including roaches, rodents, bedbugs, fruit, and fruit flies, but not gnats. Review of Hall 300 pest control reports showed that from mid-February to mid-March multiple staff observations of water bugs and gnats were documented but not addressed. The facility’s insect and rodent control policy stated that the facility would maintain an effective pest control program to provide an insect- and vermin-free food service department, but the documented and observed presence of gnats in resident areas demonstrated a failure to implement an effective program.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program for a resident on enhanced barrier precautions. The resident was an adult female with cervical spina bifida and paraplegia, with intact cognition and an indwelling urinary catheter. Her comprehensive care plan documented that she was on enhanced barrier precautions, with interventions requiring staff to don both gown and gloves for high-contact care activities such as linen changes, resident hygiene, transfers, dressing, toileting/incontinence care, bed mobility, wound care, enteral feeding care, catheter care, trach care, bathing, or other high-contact activities. An enhanced barrier precaution sign was posted at the room entrance instructing staff to wear a gown and gloves during incontinence care, and a plastic cabinet with drawers containing PPE was located outside the room. On the observed date and time, a CNA exited the resident’s room and reported she had just provided incontinence care. When questioned, the CNA stated she wore gloves but not a gown and believed a gown was only required if the resident had a certain type of infection or an infected wound, despite the posted sign specifying gown and glove use for incontinence care and the resident’s known urinary catheter. The resident reported that some staff wore a gown and gloves during incontinence care and some did not. Nursing staff, including an LVN and the ADON, stated that the resident was on enhanced barrier precautions due to the urinary catheter and confirmed that staff should wear appropriate PPE, including a gown and gloves, when providing incontinence care to prevent cross-contamination. The facility’s written Enhanced Barrier Precautions policy required targeted gown and glove use during high-contact resident care activities for residents with wounds and/or indwelling medical devices, including urinary catheters.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to ensure that residents were protected from abuse and neglect, as evidenced by an incident in which one resident slapped another resident in the face. Both residents involved had severe cognitive impairments and resided in the memory care unit. The resident who was slapped had diagnoses including dementia and required assistance with personal care, while the resident who committed the act had dementia, schizophrenia, bipolar disorder, and a cognitive communication deficit. The incident was witnessed indirectly when a staff member heard a slap and another resident pointed out the aggressor. The resident who was slapped touched her face and indicated she was okay, but due to her cognitive status, she did not remember the incident or provide further information during interviews. The resident who committed the act had a documented history of verbal behavioral symptoms and poor impulse control, as reflected in her care plan. Prior to the incident, her care plan included interventions for managing behaviors, but she was not on 1:1 monitoring until after the event. Staff interviews revealed that the resident had previously exhibited verbal aggression but had not been observed physically assaulting others before this incident. The staff member present at the time did not witness the actual slap but responded after being alerted by another resident and by the noise. The facility's policy states that residents have the right to be free from abuse, including abuse by other residents. The incident was reported to the appropriate staff, and documentation confirmed that the event occurred. Both residents were unable to recall the incident during follow-up interviews, likely due to their cognitive impairments. The deficiency centers on the facility's failure to prevent the occurrence of resident-to-resident abuse, despite known behavioral risks and care plans indicating the potential for such behaviors.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse for two residents in the memory care unit. One resident, with diagnoses including dementia and cognitive communication deficit, was assessed as having severely impaired cognition and a history of verbal behavioral symptoms. Another resident, also with severe cognitive impairment and additional psychiatric diagnoses, was identified as having potential for physical behaviors and poor impulse control. An incident occurred in which the second resident slapped the first resident on the face, as reported by a CNA who heard the slap and was informed by another resident. The CNA confirmed that the resident admitted to slapping the other after being told to 'shut up.' Interviews with staff revealed that the incident was not directly witnessed by staff, but was reported by a resident and confirmed by the CNA through resident admission. The affected resident was unable to recall or confirm the incident due to cognitive impairment. Staff interviews indicated that the resident who committed the act had a history of verbal outbursts but had not previously been observed to hit others. The facility's policy required staff to identify, correct, and intervene in situations of possible abuse or neglect, and to provide ongoing education on abuse prevention and reporting. Despite these policies, the facility did not effectively prevent the incident of resident-to-resident abuse. The event was not immediately observed by staff, and the response relied on secondhand reports and post-incident interviews. The facility's failure to ensure adequate supervision and implementation of abuse prevention policies resulted in a resident being physically struck by another resident, with the incident only coming to light after the fact through indirect observation and resident statements.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
A certified nursing assistant (CNA) failed to follow a resident's care plan and facility policy by operating a mechanical lift alone during a transfer, despite the requirement for two staff members. The resident involved had diagnoses including obesity, lack of coordination, and muscle weakness, and required maximal assistance with activities of daily living, as documented in her care plan and MDS assessment. The CNA attempted to transfer the resident back to bed after a shower using the Hoyer lift without assistance, resulting in the lift collapsing and both the resident and the lift falling to the floor. The incident led to the resident sustaining five fractured ribs, as confirmed by hospital records. The resident initially underwent an x-ray at the facility, which did not reveal concerns, but continued to experience pain and was later diagnosed with rib fractures at the emergency room. The resident reported that the CNA performed the transfer alone both to and from the shower, and that after the fall, additional staff were called to assist in returning her to bed. Interviews with facility staff, including the administrator and DON, confirmed that two staff members are always required to operate the mechanical lift, and that this policy was in place at the time of the incident. The CNA admitted to operating the lift alone, citing staffing shortages and pressure to provide care. Other CNAs on shift denied being asked for assistance. The facility's policy and staff statements consistently indicated that using the lift alone was not permitted and was considered unsafe.
Failure to Ensure Call Light Accessibility for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call light systems, as required by their care plans and facility policy. For one resident with a history of left femur fracture and moderate cognitive impairment, the call light was found inside her nightstand and not within her reach while she was lying in bed. The resident was unable to identify the location of her call light when asked. For another resident with severe cognitive impairment and muscle weakness, the call light was located on the side of the bed against the wall, also out of reach, and the resident did not know where it was. Both residents required substantial assistance with activities of daily living and had care plans specifying that call lights should be within reach. Multiple staff interviews confirmed that call lights are expected to be within reach of all residents and that staff are responsible for checking this during regular rounds. Despite these expectations and documented in-service training on the subject, observations on the day of the survey revealed that the call lights for both residents were not accessible. Staff acknowledged the importance of call light accessibility for resident safety and indicated that rounds were conducted to check for this, but the deficiency was still observed during the survey.
Failure to Properly Store Respiratory Devices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents who required it, as evidenced by improper storage of respiratory devices for three residents. Observations revealed that a resident's nebulizer mask was left sitting on top of the nebulizer on a chair after use, another resident's nasal cannula was found on the floor near the oxygen device and not bagged, and a third resident's inhaler was stored unbagged inside a nightstand. These actions were not consistent with professional standards of practice, the residents' care plans, or their goals and preferences. Interviews with nursing staff, including RNs, ADONs, and the DON, confirmed that respiratory devices such as nasal cannulas and breathing masks should be bagged when not in use to prevent infection. Staff acknowledged that it was their responsibility to ensure proper storage of these devices during rounds. The facility's respiratory care policy also indicated the importance of safe and evidence-based respiratory services for residents requiring such care.
Failure to Ensure Accessible Call Light Systems for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of three residents were accessible, as required to reasonably accommodate their needs and preferences. Observations revealed that the call lights for these residents were not within their reach while they were in bed. Specifically, one resident's call light was placed on the nightstand next to the bed, another's was wrapped around the wall fixture, and a third resident's call light was found inside a nightstand drawer. These placements made it impossible for the residents to access the call lights when needed. The residents involved had significant cognitive and physical impairments. One resident had severe dementia and required substantial assistance with self-care, another had Alzheimer's disease and muscle atrophy with severely impaired cognition, and the third had a history of stroke with hemiparesis and moderately impaired cognition. Their care plans included interventions to keep call lights within reach due to their high risk for falls, impaired mobility, and communication deficits. Despite these documented needs, staff did not ensure the call lights were accessible during the surveyors' observations. Interviews with staff, including a CNA, ADON, RN, and the Administrator, confirmed that it was the facility's expectation and standard practice to keep call lights within reach of residents. Staff acknowledged that call lights were sometimes moved during care and not returned to an accessible position, and that regular rounding should include checking call light placement. The facility did not have a specific policy related to call lights.
Failure to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to ensure that wheelchairs used by four residents were maintained in a safe condition, which could potentially lead to accidents or injuries. Observations revealed that the wheelchairs of these residents had cracked armrests with exposed foam, which were not reported or repaired in a timely manner. Despite routine inspections being claimed, there was no documentation of repair requests for these specific wheelchairs, indicating a lapse in the maintenance process. Resident #19, a male with dementia and mobility issues, was observed in a wheelchair with cracked armrests. Similarly, Resident #39, who has severe cognitive impairment and is dependent on staff for assistance, was found in a wheelchair with cracked armrests. Resident #15, a female with dementia and hemiplegia, was also observed in a wheelchair with a cracked and missing armrest. Resident #10, who has Alzheimer's and requires supervision for certain activities, reported a loose handle that was fixed but did not report the cracked armrests. Interviews with staff revealed inconsistencies in the reporting and repair process for wheelchair maintenance. The CNA mentioned that repairs were noted in a maintenance log, but the LVN was unaware of the procedure. The Administrator stated that repairs should be reported through an online portal or to a supervisor, but there was no documentation of such reports for the affected residents. The Director of Nursing and Maintenance Supervisor also provided conflicting information about the repair process, highlighting a lack of clear procedures and communication regarding wheelchair maintenance.
Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specific deficiencies included the failure to label and date food items with their received or expiration dates, the presence of expired whipping cream that was not disposed of, and the storage of open food items in the refrigerator that were not sealed. These lapses were identified through observations of various food storage areas, including a drink dispenser containing an unidentified yellow liquid without a label or preparation date, and refrigerators containing expired and improperly stored food items. Interviews with the Dietary Manager (DM) and Dietary Coordinator (DC) revealed that staff were expected to label and date all food items upon receipt and check expiration dates before storage. The DM acknowledged that the ham exposed to air should have been sealed, and the unidentified lunch meat should have been labeled with an open or use-by date. The DC emphasized the risks associated with improperly labeled or expired food, including potential allergic reactions and foodborne illnesses. The facility's Food Storage and Supplies Policy, as well as the U.S. FDA Food Code, were referenced, highlighting the importance of proper food labeling and storage to prevent contamination and ensure safety.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by deficiencies found in two resident rooms and one hallway. In Resident #43's bathroom, the safety grab bar was loose, and the water barrier next to the toilet had separated from the wall, revealing a large gap. Additionally, the tiles around the base of the toilet were separated, exposing the bare floor. Resident #43 was unable to answer questions about the bathroom condition. In Resident #61's bathroom, the sink had no running water, and the stopper was inoperable, keeping it closed. During an observation, Resident #61 asked the ADON where he could wash his hands, as there was no water in his room. The ADON provided hand sanitizer and explained that the water had been turned off to fix the sink. Resident #61 was unable to answer further questions. Additionally, in the 300 Wing (Secure Unit) hallway, a section of the handrail was missing plastic endcaps, exposing sharp edges of sheet metal. Interviews with staff revealed a lack of awareness and communication regarding maintenance issues. The ADM and Maintenance Supervisor were unaware of the deficiencies, and no reports were found in the maintenance logs or the new phone app reporting system. The DON acknowledged the potential risks posed by these deficiencies, such as falls, skin tears, and infection control issues. Record reviews showed no evidence of maintenance issues being reported for the 300-Hall Secure Unit over the past three months.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for residents on the female locked unit. During an observation, it was noted that the computer on Medication Cart 1 was left unlocked and unattended, displaying resident medications. This occurred while LVN A assisted residents to various locations within the unit, leaving the computer exposed near the front door and facing the common area. Several residents walked past the unlocked computer, which was not secured as required by facility policy. LVN A acknowledged awareness of the need to lock the computer but underestimated the risk of unauthorized access by residents. The facility's policy on resident rights, revised in November 2021, mandates that resident information be maintained as confidential.
Failure to Ensure Proper Footwear Leads to Fall Risk
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that the resident's shoes were worn properly, which could lead to falls. The resident, an elderly female with Alzheimer's, unspecified abnormalities of gait and mobility, and a history of falling, was observed walking around the common area with her heels not completely in her shoes. The resident stated she did not receive assistance with putting on her shoes, and due to her severe cognitive impairment, a full interview was not possible. The resident's care plan, which was revised prior to the observation, included interventions to ensure footwear was worn appropriately when ambulating or mobilizing in a wheelchair. However, a CNA reported that the resident often dressed herself and put on shoes incorrectly, and the CNA would only correct the shoes if the resident allowed. The facility's administrator acknowledged that staff should have been using the resident's care plan to determine fall risk interventions and that improper footwear could lead to falls. The facility's policy on preventive strategies to reduce fall risk emphasized the importance of properly fitting footwear with slip-resistant soles.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, Medication Cart 1 was found unlocked and unattended on the female locked unit. This cart, containing medications, was accessible to both residents and staff because the drawers could be easily opened. The incident occurred while LVN A was assisting residents in various activities, leaving the cart unattended near the front door of the locked unit. Several residents were observed walking past the unlocked cart, which was facing the common area. In an interview, LVN A, who had been working at the facility intermittently since 2017, acknowledged that the medication cart should have been locked. However, she did not believe that any residents would tamper with the cart. The facility's administrator confirmed that the cart should have been locked whenever it was not in the direct sight of LVN A. A review of the facility's medication administration procedure, revised in 2017, indicated that the medication cart must be completely locked or otherwise secured after the medication administration process is completed.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were in place to prevent accidents for a resident identified as a fall risk. This resident, who had severe cognitive impairment and a history of multiple falls, was left unsupervised in the dining room, resulting in a fall from his wheelchair. The fall led to a bilateral subdural hematoma, requiring hospitalization. Prior to this incident, the resident had also fallen from his bed, sustaining a hematoma, indicating a pattern of inadequate fall prevention measures. The resident's care plan, revised earlier in the year, identified him as at risk for multiple falls and included interventions such as educating the resident, family, and caregivers about safety, using a floor mat while in bed, and reminding the resident to use the call light for assistance. Despite these measures, the resident experienced several falls throughout the year, including incidents in February, April, September, and October, suggesting that the interventions were insufficient or not properly implemented. Interviews with staff revealed that there was typically a nurse present in the dining area during meal times, but on the day of the incident, both the nurse and a CNA were absent from the dining room simultaneously, leaving the resident unsupervised. The staff acknowledged that the resident was impulsive and had a tendency to stand up despite his unsteady gait. The facility's failure to provide continuous supervision and appropriate interventions for the resident's specific fall risk contributed to the incident.
Failure to Review and Revise Comprehensive Care Plan
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive assessment and quarterly review assessments. This deficiency was identified for one resident who had been admitted with diagnoses including dementia, acute kidney failure, and difficulty in walking. The resident's care plan, which was last revised in August 2024, indicated a risk for multiple falls, with interventions such as educating the resident, family, and caregivers about safety and using a floor mat while the resident is in bed. However, the last care plan conference was held in May 2024, and the subsequent quarterly meeting that should have occurred in August 2024 was not conducted. Interviews with the Social Worker and the Administrator revealed that the Social Worker was responsible for ensuring that care plan meetings were held quarterly. The Social Worker admitted to overlooking the scheduling of the care plan conference, and the Administrator confirmed that there was no reason for the meeting not being held. The facility's policy on comprehensive care plans stated that the resident's care plan should be reviewed after each admission, quarterly, annual, and/or significant change MDS assessment, and revised based on changing goals, preferences, and needs of the resident. The failure to conduct the care plan meeting as scheduled could affect residents by placing them at risk for not having their individual needs met.
Failure to Obtain Laboratory Services for Resident
Penalty
Summary
The facility failed to obtain laboratory services to meet the needs of Resident #13, who was one of the three residents reviewed for laboratory services. The resident, who had severe cognitive impairment and was frequently incontinent, had a physician's order for a urine analysis (UA) on 9/23/24, which was not collected. The Director of Nursing (DON) reported that the UA was canceled on 9/26/24, possibly due to the resident resisting staff, but no alternative actions were taken, and the physician was not notified of the inability to collect the specimen. Multiple attempts to collect the UA were unsuccessful due to contamination, as noted in a progress note by LVN A on 9/26/24. The nurse practitioner (NP) who ordered the UA was unaware of the collection issues, and the facility's staff did not communicate the problem to her. The laboratory service provider confirmed that the UA was canceled after three failed attempts to collect the specimen on consecutive days. The facility lacked a specific policy for handling laboratory services, UAs, or UTIs, and the existing policy on notifying physicians of changes in status was not followed. Resident #13 was later diagnosed with a urinary tract infection (UTI) during a hospital visit for an unrelated event on 10/04/24. The resident was prescribed antibiotics and returned to the facility. Interviews with facility staff, including the DON, LVN C, and ADON D, revealed a lack of clarity and communication regarding the collection and monitoring of laboratory tests, contributing to the deficiency in care for Resident #13.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure each resident was treated with respect and dignity, specifically in the case of two residents. One incident involved a Licensed Vocational Nurse (LVN) who slammed her hand on a bedside table and yelled 'Sit' at a resident with dementia and cognitive impairment. This resident, who had a history of falls, was standing up when the LVN took this action. The LVN later explained that she was trying to prevent the resident from falling but acknowledged that there were other ways she could have redirected the resident. The resident was unable to fully communicate due to cognitive limitations, but he did not express any concerns during the interview. Another resident expressed dissatisfaction with how the staff treated him and other residents, stating that the staff spoke to them in a demeaning manner and often ignored them. The facility's administrator confirmed that staff should not yell or hit objects in front of residents, acknowledging that such actions could violate resident rights. The facility's policy on resident rights emphasizes the importance of treating residents with dignity, courtesy, consideration, and respect.
Failure to Supervise Resident While Smoking
Penalty
Summary
The facility failed to establish and follow policies regarding smoking safety, which resulted in a resident being left unsupervised while smoking. Resident #3, who has severe cognitive impairments due to dementia and Alzheimer's, was observed smoking outside without staff supervision. The resident's care plan and smoking assessment indicated that she required direct supervision while smoking to prevent injury. However, on the day of the observation, the CNA responsible for supervising the residents left to escort other residents back to their unit, leaving Resident #3 alone. The LVN, who was supposed to take over supervision, was occupied with other tasks and did not maintain a direct line of sight to the resident, contrary to the facility's smoking policy. Interviews with the staff revealed a misunderstanding and miscommunication regarding the supervision responsibilities. The CNA believed the LVN would take over supervision, while the LVN was preoccupied with medication administration and blood sugar checks. The facility's administrator confirmed that residents should be within the direct view of staff while smoking, as per the smoking policy. The failure to adhere to these policies and ensure proper supervision placed Resident #3 at risk for smoking-related injuries.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information on 05/17/24. Observation at 3:15 PM on that day revealed that the posted staffing information was dated 04/23/24. In an interview at 3:40 PM, the Assistant Director of Nursing (ADON) admitted responsibility for the daily posting and acknowledged the oversight. The ADON stated that she usually printed and posted the staffing ratio daily but had forgotten to update the posting for 05/17/24, leaving the outdated information from April. This failure to update the daily staffing information could prevent residents from accessing current staffing data and facility census information.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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