San Jose Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 406 Sharmain Pl, San Antonio, Texas 78221
- CMS Provider Number
- 45E312
- Inspections on file
- 26
- Latest survey
- April 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at San Jose Nursing Center during CMS and state inspections, most recent first.
The facility did not revise or update the comprehensive care plans for four residents, resulting in care plans that lacked current medical justifications, measurable timeframes, and appropriate interventions for devices such as side rails and Geri-chair restraints. Staff interviews and record reviews confirmed that care plans were outdated, missing necessary details, and not aligned with current physician orders or resident needs.
Nursing staff did not attempt less restrictive alternatives, failed to review risks and benefits, and did not obtain informed consent or complete required assessments before using bed rails for four residents, including individuals with cognitive impairment, physical disabilities, and psychiatric diagnoses. Required documentation and periodic reassessment were also lacking, as confirmed by interviews with the DON and ADON.
Dietary staff served meals that did not match the posted menu, made unapproved substitutions without maintaining a substitution log, and used outdated menus. The dietician had not reviewed or approved the current menus for several months, and updated menus were not posted or available. These failures affected all residents and did not comply with facility policy requiring dietician review and menu adherence.
Staff served cold chicken penne pasta salad and a mechanical vegetable mixture at temperatures above 41°F, contrary to professional standards and facility policy. The food was prepared earlier in the day, refrigerated, and then placed on ice, but did not reach the required cold holding temperature before being served to residents on regular and mechanical soft diets.
A resident with severe cognitive impairment, dementia, and muscular atrophy was found with her call light on the floor and not within reach, despite her care plan requiring it to be accessible and staff reminders to use it. Staff confirmed the call light was not accessible and acknowledged the resident needed reminders to use it, but the device remained out of reach after maintenance work, contrary to facility policy.
A MAR binder containing residents' medication information was left open and unattended on a medication cart in a hallway, allowing staff and visitors to view confidential information. An LVN admitted to stepping away briefly, and the DON confirmed that the binder should not have been left exposed.
A resident with cerebral palsy and moderate cognitive impairment was observed using a wheelchair with both armrests cracked and torn, exposing the padding. The maintenance worker, responsible for repairs, had not recently checked the wheelchair and was unaware of the issue due to lack of staff reporting. The DON confirmed that periodic checks and timely replacement of torn armrests were expected, but no policy for equipment maintenance was provided during the survey.
A resident with severe cognitive impairment and multiple chronic conditions was consistently placed in a Geri-chair with a tray table restraint whenever out of bed, without removal for meals or activities and without ongoing re-evaluation or documentation of the need for the restraint. Staff confirmed the restraint was always used for fall prevention and at the family's request, but records lacked evidence of less restrictive alternatives or regular assessment, resulting in a deficiency related to improper use of physical restraints.
A resident with severe cognitive impairment and multiple psychiatric diagnoses, including depression and psychotic disorder, was not referred for a Level I PASARR screening after being newly diagnosed with additional mental health conditions. The DON did not consult with the psychiatric NP or initiate the required referral, despite facility policy mandating PASARR coordination for residents with mental illness.
A resident with Parkinson's Disease and Dementia, who was bedbound and dependent on staff for all ADLs, did not receive assistance with washing her face or brushing her teeth as required. The resident reported feeling dirty and noted delays in staff response to her requests for help. CNAs confirmed that hygiene care was not provided that morning, and the DON acknowledged the resident's need for total care.
A resident with severe cognitive impairment and multiple diagnoses received scheduled DuoNeb nebulizer treatments, but the nebulizer mask was found uncovered, undated, and with a dried white substance present. Staff interviews revealed inconsistent documentation and lack of clarity regarding equipment maintenance, and the DON was unaware of the resident's ongoing respiratory treatments.
A resident's nutrition assessment form contained multiple inaccuracies, including incorrect admission date, date of birth, height, and ideal body weight range. The dietician made handwritten corrections to some information but was unaware of other errors, and also reported computer issues. The resident had severe cognitive impairment and significant weight loss, and the DON acknowledged that these documentation errors could affect the accuracy of dietary assessments.
A resident receiving hospice care did not have hospice services documented in her care plan or medical record, and hospice nursing visit notes were missing from both the hospice binder and facility records. Facility nurses were unaware that hospice documentation was required, and communication with the hospice provider was limited to verbal reports, resulting in incomplete records and potential gaps in care coordination.
Sixteen double occupancy rooms were found to have less than the required 80 square feet per resident, with measurements ranging from 61.9 to 79.3 square feet. Nineteen residents were residing in these rooms at the time of the survey, and the Administrator confirmed the deficiency, noting a waiver was in effect and room sizes had not changed.
The facility failed to implement policies to prevent abuse, neglect, and exploitation, as two staff members were not screened through required registries. Despite working shifts, NA A and NA B had not undergone annual background checks, violating facility policies and potentially affecting all residents.
The facility failed to verify that two nurse aides had completed the required training and certification before allowing them to work. Despite lacking documentation of their certification, both aides were scheduled and worked shifts. The administrator was aware of the situation, noting that one aide had failed the certification test and did not plan to retake it. This deficiency could impact all residents by having uncertified staff provide direct care.
The facility failed to provide required training on abuse, neglect, and exploitation reporting procedures to two staff members, NA A and NA B, for the year 2024. This deficiency was identified through a review of personnel files and in-service attendance records, revealing that both staff members did not attend the necessary training. Interviews with the DON and Administrator confirmed the oversight, highlighting a lapse in adherence to the facility's policy on staff training.
The facility failed to maintain resident assessments completed within the previous 15 months in the residents' active medical records. Six residents' MDS assessments were stored in a locked cabinet in the DON/Owner's office, making them inaccessible to staff when needed. The facility's leadership admitted they were unaware that these assessments should be part of the master record in the residents' active medical records.
The facility failed to ensure a safe, functional, sanitary, and comfortable environment in an adjacent building used for laundry, food storage, and maintenance. Observations revealed safety hazards, including improper handling of electrical cords and gas connections, storage of flammable materials, and exposed live electrical wires. The Administrator acknowledged the issues and stated that they would be corrected immediately.
A facility failed to ensure accurate MDS assessments for a resident, incorrectly listing psychiatric diagnoses not supported by the medical record. The DON/Owner admitted to the error, attributing it to the high volume of assessments being completed at the time.
The facility failed to develop and implement comprehensive person-centered care plans for two residents, resulting in one resident having no care plan and another having an incomplete care plan. The DON acknowledged missing documents due to chart thinning and OIG requests, and the facility lacks a specific Care Plan policy.
The facility failed to provide the required minimum of 80 square feet per resident in 16 double occupancy rooms, affecting 19 residents. The Administrator confirmed the deficiency and stated that a room waiver was in effect, although the room sizes had not changed.
Failure to Revise and Update Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to revise and update the comprehensive care plans for four residents as required, resulting in care plans that did not accurately reflect the residents' current medical conditions, interventions, or measurable timeframes. For one resident with severe cognitive impairment and functional limitations, the care plan for the use of a half side rail did not specify the medical condition necessitating the side rail, lacked measurable timeframes, and did not include reassessment for safe use. The Director of Nursing (DON) acknowledged that the care plan was not updated to reflect the resident's current needs, despite being aware of the requirement. Another resident with dementia, diabetes, and significant weight loss had a care plan that was not revised to reflect current dietary orders or interventions following the weight loss. The care plan contained outdated and undated handwritten notes, lacked measurable timeframes, and did not align with the resident's current physician orders for diet. Similarly, a third resident with vascular dementia and a history of amputation had a care plan for the use of a half side rail that did not document the medical reason for the side rail, did not include timeframes, and omitted the need for reassessment, as confirmed by the Assistant Director of Nursing (ADON). A fourth resident with dementia, hypertension, and diabetes was observed multiple times using a Geri-chair with a tray table, which functioned as a physical restraint. The care plan for this resident did not include interventions for removing the tabletop or assessing the continued need for the restraint, nor did it provide measurable timeframes for goals. Observations showed the resident was frequently in the Geri-chair with the tray table attached, and staff interviews confirmed the resident was always up in the chair with the tabletop. The facility was unable to provide a care plan policy when requested.
Failure to Assess, Obtain Consent, and Use Alternatives Prior to Bed Rail Use
Penalty
Summary
Nursing staff failed to follow required procedures before the use of side or bed rails for four residents. Specifically, staff did not attempt to use less restrictive alternatives prior to installing bed rails, did not review the risks and benefits of bed rail use with the residents or their representatives, and did not obtain informed consent in several cases. Additionally, assessments for the safe use of bed rails were either not completed or not documented as required. For one resident with severe cognitive impairment and impaired vision, the care plan included the use of a side rail for bed mobility, but there was no documentation of the risks and benefits, no evidence of less restrictive alternatives being tried, and the consent form was incomplete and unsigned by a physician. Another resident with moderate cognitive impairment and multiple psychiatric diagnoses had a physician's order and care plan for side rail use, but there was no consent or assessment for the use of the side rail, and the last assessment indicated no side rail was in use. A third resident with moderate cognitive impairment, cerebral palsy, and seizure disorder had a care plan and physician's order for side rail use, but lacked both a consent and an assessment for the device. The fourth resident, who had no cognitive impairment but had bilateral lower extremity amputations, used a side rail for mobility and repositioning, but the consent did not include risks and benefits, and there was no documentation of less restrictive alternatives or a current reassessment. Interviews with the DON and ADON confirmed that required procedures, including obtaining consent, assessing for safety, and periodic reassessment, were not consistently followed.
Failure to Follow, Update, and Review Menus by Dietician
Penalty
Summary
Dietary staff did not follow the posted menu for a lunch meal, serving pinto beans instead of the scheduled pirogues, without maintaining a substitution log or consulting the dietician about the change. The Food Service Supervisor (FSS) admitted to not posting the monthly menu at a glance, not keeping a substitution log for several months, and making menu changes based on personal assumptions about resident preferences. The FSS also used outdated menus from June 2024, as updated menus were not available or posted, and did not communicate menu changes to the dietician prior to implementation. The facility failed to ensure that the dietician reviewed or approved updated menus for approximately five months, as the updated menus were sent to a sister facility and not obtained by the administrator. The dietician confirmed she had not reviewed or signed the current menus and that dietary staff were using outdated menus without access to menu recipes, substitution options, or purchase guides. Facility policy required dietician approval of menus and adherence to nutritional standards, but these procedures were not followed, affecting the entire resident population.
Cold Food Items Served Above Safe Temperature Standards
Penalty
Summary
The facility failed to store, prepare, and serve cold food items in accordance with professional food service safety standards. Specifically, during the evening meal service, the chicken penne pasta salad and the mechanical vegetable mixture were served at temperatures above the required 41 degrees Fahrenheit. Observations showed that the chicken penne pasta salad was at 62 degrees F and the mechanical vegetable mixture was at 70 degrees F, despite being placed on ice in the steamtable. Staff interviews confirmed that these items were intended to be served cold and that the proper serving temperature should be 41 degrees F or below. The food had been prepared earlier in the afternoon and placed in the refrigerator, but did not reach the required temperature before being served. Further review of facility policy and the FDA Food Code confirmed that cold foods must be maintained at or below 41 degrees F. The Food Service Supervisor and other staff acknowledged the temperature requirements and the potential for food to go bad if not properly cooled. The deficiency was observed as the cold food items were served to residents on both regular and mechanical soft diets at temperatures above the required threshold, in direct violation of professional standards and facility policy.
Failure to Ensure Call Light Accessibility for Resident with Cognitive and Physical Impairments
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding access to the call light. Observations revealed that the resident's call light was on the floor and not within reach, despite the care plan indicating that the call light should be kept within the resident's reach and that the resident should be reminded to use it for assistance. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and muscular atrophy, was severely cognitively impaired, required partial to moderate assistance for mobility, and was always incontinent of bowel and bladder. The resident was able to lift her left arm and grasp a hand when prompted, but her speech was garbled, making it unclear if she could effectively use the call light without reminders. Staff interviews confirmed that the call light was not accessible to the resident and acknowledged that it should not have been on the floor. Maintenance had been working on the call light earlier, but after their departure, the call light remained out of reach. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both recognized that the resident could use the call light with verbal reminders and that not having it within reach could prevent the resident from receiving needed assistance. Facility policy required CNAs to attend to residents' needs at all times, but this was not followed in this instance.
Failure to Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical records when a Medication Administration Record (MAR) binder was left open and unattended on a medication cart in the west wing hallway. The open binder, which contained information on residents' prescribed medications and administration times, was visible to anyone passing by, including staff and visitors. This lapse occurred when an LVN stepped away from the cart to put away laundry, leaving the MAR binder exposed. Both the LVN and the Director of Nursing acknowledged that the MAR binder should not have been left open and unattended. The facility's medical records policy was requested but not provided by the time of the survey exit.
Failure to Maintain Wheelchair Armrests in Good Repair
Penalty
Summary
A deficiency was identified when a resident with cerebral palsy, moderate cognitive impairment, and impaired lower extremity range of motion was observed using a wheelchair with both armrests cracked and torn, exposing the padding. The resident's care plan noted a self-care deficit related to cognitive impairment, and the resident relied on the wheelchair for mobility. Multiple observations confirmed the poor condition of the wheelchair armrests over two days. Interviews with the maintenance worker revealed that he was responsible for replacing torn armrests but had not checked the resident's wheelchair recently and had not received reports from staff about the issue. The Director of Nursing stated that the maintenance worker was expected to periodically check wheelchairs for functionality and replace torn armrests to prevent potential skin tears. Despite requests, the facility was unable to provide a policy for maintaining resident equipment in good working order before the survey exit.
Failure to Ensure Resident Freedom from Unnecessary Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints imposed for convenience and not required to treat medical symptoms, as observed over a four-day survey period. The resident, an elderly female with diagnoses including dementia, hypertension, and diabetes, was consistently seated in a Geri-chair with a tray table attached whenever she was out of bed. The tray table was not removed during meals or activities, and there was no documentation of ongoing re-evaluation of the need for the restraint. Staff interviews confirmed that the tray table was always used when the resident was out of bed, and alternative interventions were not documented or attempted prior to or after the use of the Geri-chair with tray table. Record reviews revealed inconsistencies and lack of clarity regarding the use of the restraint. The resident's care plan noted the use of the Geri-chair with or without a tabletop to prevent falls and serve as a table for activities, but did not include interventions for removing the tabletop or assessing the continued need for the restraint. Physician orders and informed consent forms referenced the use of the Geri-chair with or without the tabletop as a safety device, but documentation of less restrictive alternatives and ongoing assessment was incomplete or missing. Physical restraint elimination assessments indicated the resident was a good candidate for restraint elimination, yet the action plan consistently stated no restraint elimination at this time, with minimal documentation of less restrictive measures or specific medical symptoms justifying the restraint. Observations during the survey showed the resident was able to move her upper body and interact with her environment, but was always restrained by the tray table when in the Geri-chair, except for one instance when she was in a wheelchair without a restraint and did not attempt to get up. Staff interviews indicated the restraint was used for fall prevention and at the request of the resident's family, but there was no evidence of regular re-evaluation or consideration of less restrictive alternatives. The facility's restraint policy referenced compliance with laws and professional judgment, but the practice observed did not align with requirements for restraint use only when necessary for medical treatment and with ongoing assessment.
Failure to Refer Resident for PASARR Screening After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was newly diagnosed with a serious mental disorder. Specifically, after a resident was diagnosed with persistent mood disorder and major depressive disorder, the facility did not refer the resident for a Level I PASARR screening as required. The resident's medical record showed multiple psychiatric diagnoses and ongoing treatment with several psychotropic medications, yet no referral was made for further evaluation through the PASARR process. During an interview, the Director of Nursing (DON) acknowledged responsibility for referring residents for Level I PASARR screening if they had a mental illness but stated she did not believe the resident had a psychiatric condition warranting the referral. The DON also indicated she had not consulted with the psychiatric nurse practitioner regarding the resident's condition. Upon reviewing the psychiatric assessment, the DON recognized that the resident could qualify for additional resources and admitted that not referring residents with mental illness for Level I evaluation could result in missed services. Facility policy requires adherence to PASARR guidelines to ensure residents with mental illness receive specialized services.
Failure to Provide Assistance with Personal and Oral Hygiene
Penalty
Summary
A deficiency was identified when a resident with Parkinson's Disease and Dementia, who was bedbound and dependent on staff for all activities of daily living (ADLs), did not receive necessary assistance with personal and oral hygiene. The resident, who primarily spoke Spanish and had moderate cognitive impairment, reported that she was unable to get out of bed and required help with all ADLs. She stated that on the day in question, staff did not assist her with washing her face or brushing her teeth, leaving her feeling dirty and unwell. She also noted that it sometimes took staff an hour or two to respond to her requests for help. Interviews with CNAs revealed that while it was their responsibility to assist residents with morning hygiene tasks such as wiping faces and brushing teeth, these tasks were not completed for this resident on the day observed. One CNA admitted she did not provide care because she was attending to another resident, and acknowledged that not brushing a resident's teeth could lead to infection. The Director of Nursing confirmed that the resident required total care and that CNAs were expected to provide assistance with personal hygiene as part of their duties. Review of facility policy supported that CNAs must attend to residents' needs at all times.
Failure to Maintain Safe and Clean Nebulizer Equipment for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident requiring respiratory care was not provided with safe and appropriate management of their nebulizer equipment. The resident, who had diagnoses including Alzheimer's disease, unspecified dementia, and muscular atrophy, was severely cognitively impaired and required assistance with mobility and activities of daily living. Physician orders indicated the resident was to receive DuoNeb treatments every six hours for five days, which was administered as scheduled. However, the resident's care plan did not include any problems or interventions related to nebulizer treatments. During observations, the resident's nebulizer mask was found uncovered, with the elastic band stretched around the nebulizer machine, and a dried white substance present on the mask. The mask and tubing were not dated or covered, and there was no documentation of when they were last changed. Interviews with nursing staff revealed that while masks and tubing were reportedly changed weekly and should be dated and covered, there was no specific documentation to confirm this practice. The Director of Nursing was unaware that the resident was still receiving nebulizer treatments and did not provide a facility policy for respiratory care when requested.
Incomplete and Inaccurate Medical Records in Nutrition Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, the nutrition assessment form for the resident contained the correct name but listed an incorrect admission date, date of birth, height, and ideal body weight range. The dietician, who completed the assessments, acknowledged crossing out and correcting the height and ideal body weight range but was unaware that the admission date and date of birth were incorrect. The dietician also reported experiencing computer issues during this process. Additionally, the resident's care plan and dietary care plan contained handwritten changes and lacked clear dating for some interventions. The resident involved had a history of dementia with behavioral disturbances, diabetes, and vitamin D deficiency, and was noted to have severe cognitive impairment, poor appetite, and significant weight loss. The DON confirmed that having incorrect information in the nutritional assessments could result in not having an accurate weight and dietary assessment for the resident. The facility's medical records policy was requested but not provided by the time of the survey exit.
Failure to Document and Communicate Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services for a newly admitted female resident with diagnoses including anxiety, chronic pain, insomnia, and depression met professional standards and principles. Specifically, the resident's hospice care was not included in her interdisciplinary care plan, and there were no hospice licensed nursing visit notes present in either her hospice binder or medical record. Facility staff nurses were unaware that hospice documentation was required as part of the resident's medical record, and communication between the facility and the hospice provider was limited to verbal reports without proper documentation. Record reviews confirmed the absence of hospice nursing notes in both the hospice binder and the resident's medical record, and interviews with staff revealed a lack of awareness regarding the need for this documentation. The only documentation present in the hospice binder was contact information for the hospice and CNA sign-in sheets, with no licensed nurse visit notes available until after the issue was identified. The DON acknowledged that not having hospice notes in the medical record affected communication regarding the resident's care.
Resident Rooms Below Minimum Square Footage Requirement
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 16 out of 32 double occupancy rooms. During interviews and record reviews, it was confirmed that these rooms, specifically rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31, did not meet the square footage requirement. The Administrator acknowledged that these rooms were below the required size and stated that a room waiver was in effect, with no changes to the room measurements. Observations of the rooms revealed that the square footage per resident ranged from 61.9 to 79.3 square feet, all below the regulatory minimum for double occupancy rooms. A review of the Resident Room and Bed Report showed that 19 residents were residing in the affected rooms at the time of the survey. No residents were present in some of the rooms during the annual survey.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures designed to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified through the review of records for two staff members, NA A and NA B, who were not screened through the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) during 2023 to 2024. Despite being employed and working shifts, these staff members had not undergone the required annual background checks to ensure their employability and certification status, as mandated by the facility's policies. The facility's administrator admitted that while original background checks were conducted at the time of hire, the necessary EMR and NAR checks had not been performed annually as required. This oversight was acknowledged despite the administrator's familiarity with the staff and their long-term employment. The facility's policy, which aligns with Chapter 253 of the Health and Safety Code, mandates that all staff must be screened through these registries to prevent the employment of individuals who have committed acts of abuse, neglect, or misconduct. The failure to adhere to these policies could potentially affect all residents by allowing unqualified staff to provide direct care.
Failure to Verify Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that two nurse aides, referred to as NA A and NA B, had completed a nurse aide program and received their certification before allowing them to serve in that capacity. Upon review of their personnel files, there was no documentation confirming that either NA A or NA B had completed the necessary training and certification. Despite this, both individuals were scheduled and worked shifts at the facility, with NA A working from 10:00 PM to 6:00 AM on January 29, 2025, and NA B scheduled for the 2:00 PM to 10:00 PM shift on January 30, 2025. Interviews conducted during the investigation revealed that the facility's administrator (ADM) was aware that both NA A and NA B had not secured their certification. The ADM acknowledged that NA B had completed the course but failed the certification test and expressed no intention to retake it. Despite understanding the state requirement for nurse aides to be certified to ensure they possess the necessary skills for direct resident care, the facility allowed these individuals to work without the proper credentials. This deficiency could potentially affect all residents by having uncertified staff provide direct care.
Failure to Provide Required Abuse and Neglect Training
Penalty
Summary
The facility failed to provide necessary training to their staff on procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property. Specifically, two staff members, NA A and NA B, did not complete the required training for the year 2024. This deficiency was identified through a review of employee personnel files and in-service attendance records, which showed that both staff members did not attend the in-service training on abuse, neglect, and exploitation held on October 4, 2024. Additionally, attempts to contact these staff members for further clarification during the investigation were unsuccessful. Interviews with the Director of Nursing (DON) and the Administrator confirmed that NA A and NA B had not completed the necessary abuse training during 2024. The DON acknowledged her responsibility for ensuring all staff are trained on abuse and neglect upon hire and annually. The facility's policy, dated October 2024, outlines the requirement for staff training on abuse prohibition practices, intervention with aggression, and reporting allegations, among other topics. However, the failure to adhere to these training requirements could potentially affect any resident and contribute to incidents of abuse or neglect.
Failure to Maintain Resident Assessments in Active Medical Records
Penalty
Summary
The facility failed to ensure that all resident assessments completed within the previous 15 months were maintained in the residents' active medical records. This deficiency was identified for six residents (Resident #1, Resident #10, Resident #13, Resident #18, Resident #21, and Resident #35) whose MDS assessments were not accessible to staff and ready for review. The MDS assessments were stored in a locked cabinet in the Director of Nursing (DON)/Owner's office, which was only accessible when the DON/Owner was on-site. This practice resulted in the MDS assessments not being available for review when needed, as observed during the state surveyor's review of the residents' charts at the nurses' station, where no MDS assessments were found in any of the six residents' charts reviewed. During interviews, the DON/Owner and the Administrator/Owner acknowledged that the MDS assessments were not kept in the residents' medical records and were instead stored separately in a locked cabinet. The Administrator/Owner explained that a former medical records staff person, who no longer worked for the company, had removed many records from the resident charts, which should not have been removed. The facility's leadership admitted they were unaware that the MDS assessments should be maintained as part of the master record in the residents' active medical records. This oversight affected the facility's ability to provide timely access to essential resident assessments, potentially impacting the quality of care provided to the residents.
Safety and Sanitation Deficiencies in Adjacent Building
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During an observation, it was noted that a building adjacent to the main nursing facility, used for laundry, food storage, and maintenance, had several safety hazards. The dryer electrical cord was wrapped around the flexible gas connection, and the flexible gas tubing connected to the dryer was held in place by a wire tie around a galvanized pipe. Additionally, the maintenance room contained flammable liquids and gases, including gas-powered lawn equipment, premixed fuel, paint thinner, and various flammable aerosol spray cans. Further observations revealed numerous live electrical wires hanging down from the ceiling in the maintenance room, some covered with black tape and others with exposed wiring where the sheath had fallen apart. During an interview, the Administrator acknowledged the use of the building for storage and laundry and mentioned that it had a different address and utility bills from the main building. The Administrator stated that the identified concerns would be corrected immediately.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the resident's status for one resident reviewed for assessments. Specifically, the facility's most recent MDS assessment for a resident included incorrect diagnoses of depression, psychotic disorder, schizophrenia, and post-traumatic stress disorder. These diagnoses were not supported by the resident's medical record or any historical data. The resident's face sheet indicated diagnoses of dementia with behavioral disturbance, hypertension, diabetes with chronic kidney disease, and hyperlipidemia, but not the psychiatric conditions listed in the MDS assessment. During an interview, the DON/Owner admitted to mistakenly checking the boxes for the incorrect diagnoses while completing the MDS assessments. She attributed the error to having completed a large number of MDS assessments at the time. The DON/Owner believed that the mistake did not affect the resident or their care. The facility did not provide a policy related to the completion of MDS assessments when requested prior to the survey exit.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet the residents' medical, nursing, and mental and psychosocial needs. Specifically, Resident #4 had no care plan in his chart, and Resident #141's care plan was incomplete, containing only two pages. Resident #4, who was severely cognitively impaired with diagnoses including nontraumatic intracerebral hemorrhage, vitamin D deficiency, hyperlipidemia, and age-related nuclear cataract, had no care plan filed in his medical chart. Resident #141, diagnosed with epilepsy, muscle weakness, anxiety, and age-related physical debility, had an incomplete care plan in his medical chart. In an interview, the Director of Nursing (DON) acknowledged that there have been situations leading to missing documents in the charts, including the hiring of someone to thin the charts and requests from the Office of Inspector General (OIG) for documents. The DON also stated that the facility does not have a specific Care Plan policy but follows federal and state regulations. This lack of comprehensive care planning for the residents reviewed indicates a failure to meet regulatory requirements for individualized resident care.
Failure to Provide Minimum Square Footage per Resident
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in 16 of 32 double occupancy resident rooms. Specifically, Rooms 5, 15, 16, 17, 19, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31 did not meet the required space per resident. The measurements of these rooms ranged from 61.9 to 79.3 square feet per resident, falling short of the regulatory requirement. This deficiency was confirmed through interviews and record reviews, with the Administrator acknowledging the issue and stating that a room waiver was in effect for these rooms, although the room sizes had not changed. During the survey, it was noted that 19 residents were residing in the non-compliant rooms at the time of the inspection. The Administrator confirmed the room sizes and the existence of a waiver but did not provide evidence that the waiver addressed the current room sizes. The lack of adequate space per resident could potentially impact the residents' activities of daily living, although no specific adverse events were documented in the report.
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.
