Shady Acres Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Newton, Texas.
- Location
- 405 Shady Acres Lane, Newton, Texas 75966
- CMS Provider Number
- 676055
- Inspections on file
- 37
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 5 (4 serious)
Citation history
Health deficiencies cited at Shady Acres Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents were not protected from sexual abuse when a male resident, with no prior documented history of sexual behaviors, inappropriately touched one female resident's breast and genital area and touched another female resident's breast without consent. Both female residents had cognitive impairments and reported the incidents to staff, with no physical injuries found. The incidents were categorized as abuse, and the male resident later admitted to inappropriate behaviors during a behavioral hospital stay.
The facility did not submit investigation results for three separate incidents of alleged abuse and injury of unknown origin to the State Survey Agency within the required 5-day period. Although investigations were completed and documented in the electronic medical record, the responsible staff member failed to manually upload the reports to the state system, resulting in delayed reporting for incidents involving two residents with allegations of inappropriate touching and one resident with an unexplained injury.
Multiple residents with severe cognitive impairments and behavioral health diagnoses were involved in repeated incidents of sexual, physical, and verbal abuse, including inappropriate sexual contact, physical aggression, and threats. Staff intervened in some cases but did not consistently update care plans, report incidents to the abuse coordinator, or ensure adequate supervision, resulting in a pattern of unaddressed abuse and neglect.
Multiple incidents of physical, verbal, and sexual aggression between residents, as well as an incident of neglect, were not reported by staff to the abuse coordinator or State Agency within required timeframes. Staff failed to follow established procedures for immediate and timely reporting after witnessing or being informed of abuse or neglect, despite residents' significant cognitive impairments and behavioral histories. Care plans were not updated to reflect new or ongoing aggressive or sexual behaviors following these events.
The facility did not consistently update or revise care plans for several residents following incidents of aggression, abuse, or significant behavioral changes. For example, a resident with severe cognitive impairment and behavioral issues repeatedly engaged in inappropriate sexual and aggressive behaviors without timely care plan updates, while other residents who experienced or exhibited aggression did not have their care plans revised to address safety or new interventions. Staff interviews confirmed that care plan updates were delayed due to workload and staffing issues, and required policy timelines for care plan development and revision were not met.
The facility failed to maintain clean oxygen concentrator filters for three residents requiring respiratory care. A resident with COPD, another with lung cancer and congestive heart failure, and a third with acute respiratory failure were all found with concentrators covered in dust and lacking proper filter maintenance. Staff interviews revealed confusion over responsibility for cleaning, leading to oversight and potential risk of decreased airflow.
A gas stove burner in the facility's kitchen failed to light, as observed during a survey. The Dietary Manager and Maintenance Director were responsible for ensuring equipment functionality, with staff trained to report malfunctions. The Maintenance Director identified a potential grease clog in the pilot nozzle and ordered a replacement part. The Administrator confirmed that all burners were operational during his last inspection.
A facility failed to accurately assess a resident's medical needs, resulting in incorrect MDS coding for insulin use. The resident, who had no diabetes diagnosis or insulin orders, was mistakenly recorded as receiving insulin injections. Staff interviews confirmed the error, which was acknowledged by the ADON responsible for the MDS. The DON noted that such inaccuracies could lead to inappropriate care.
A facility failed to maintain an effective infection control program, as a resident's pleural drain bag was found on the floor, contrary to care plan directives. The resident, with lung cancer and memory issues, was dependent on ADLs. Staff interviews confirmed the drain bag should not be on the floor to prevent infection, but the facility lacked a formal policy for handling pleural drain bags.
A resident at high risk for falls, with Alzheimer's and Parkinson's, experienced an unwitnessed fall resulting in a laceration above her eye due to the absence of a fall mat. The care plan did not include a fall mat as an intervention, and staff oversight led to the mat not being placed by the bed. Facility policies on safety and fall risk management were not followed.
A resident with dementia and schizophrenia was verbally abused by a CNA, who made intimidating remarks while attempting to get the resident out of bed. The Administrator overheard the incident and confirmed the CNA's inappropriate behavior. Despite prior training on abuse prevention, the CNA admitted to raising her voice due to personal stress. The resident required supervision and assistance with ADLs and had behavioral issues, which may have contributed to the situation.
A resident with Alzheimer's and a history of falls experienced a witnessed fall in the lounge area, resulting in a right hip fracture. The facility reported the incident as neglect to TULIP but did not conduct a thorough investigation or submit a 5-day report, believing the incident was not reportable. The QA LVN and Administrator attempted to delete the report but did not confirm its removal, failing to adhere to the facility's policy on reporting and investigation.
A resident with Alzheimer's, dementia, and Parkinson's was at high risk for falls, but the facility failed to include a fall mat in her care plan. This oversight led to two incidents where the resident sustained injuries from falls. Staff interviews confirmed the care plan should have included a fall mat, and the facility's policies emphasized the need for specific interventions to reduce accident risks.
A facility failed to provide adequate supervision and safety measures for residents who smoke, resulting in a serious incident where a resident on oxygen therapy sustained burns after her oxygen caught fire. The incident involved two other residents who were smoking in a non-designated area without supervision. Staff were unaware of residents' smoking statuses and failed to enforce policies regarding smoking materials, contributing to the unsafe conditions.
A resident using oxygen sustained burns after smoking in a non-designated area with two other residents. The facility failed to supervise the residents, allowed smoking materials in rooms, and did not reassess smoking safety. Staff were unaware of smoking policies, contributing to the incident.
The facility failed to implement comprehensive care plans for three residents regarding smoking safety. One resident with severe cognitive impairment was observed smoking while on oxygen without a care plan addressing smoking safety. Another resident, cognitively intact, did not comply with the smoking policy and kept smoking supplies in his room, while a third resident's care plan was not updated after being found with cigarettes. Staff were unaware of residents' smoking habits and supervision needs, increasing the risk of unsafe smoking practices.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from sexual abuse, resulting in a deficiency related to resident rights and protection from abuse. One male resident, who was cognitively intact and had diagnoses including mood disorder, dementia, and anxiety disorder, entered the room of a female resident and inappropriately touched her breast and genital area. The female resident, who was moderately cognitively impaired with diagnoses including spina bifida, anxiety disorder, and diabetes, reported the incident to staff. The incident was not witnessed, and the resident stated she told the staff the next day. The male resident denied the allegations at the time, and there was no prior documented history of sexual behaviors for him in the facility before this incident. A second female resident, who had a history of stroke, aphasia, anxiety disorder, and diabetes, reported to staff that the same male resident had touched her breast without consent on an unidentified date. This resident was also moderately cognitively impaired and had difficulty communicating due to her medical condition. The incident was reported after the resident became withdrawn and stopped participating in activities, which was noticed by the activity director. Upon questioning, the resident indicated she had been touched inappropriately. The male resident was already under increased monitoring at the time this second allegation was reported. Both incidents were categorized as abuse, and assessments conducted by nursing staff found no physical injuries to either female resident. The facility's records indicate that staff were able to identify abuse reporting procedures and immediate intervention steps, but the deficiency occurred due to the failure to prevent the male resident from accessing and inappropriately touching the female residents. The male resident later admitted to inappropriate behaviors during a behavioral hospital stay, but continued to deny the allegations to facility staff. There was no documentation of prior sexual behavior history for the male resident before these incidents.
Failure to Timely Report Investigation Results of Abuse and Injury Allegations
Penalty
Summary
The facility failed to report the results of all investigations of alleged abuse, neglect, or injury of unknown origin to the administrator or designated representative and to the State Survey Agency within 5 working days, as required by regulation and facility policy. Specifically, for three separate incidents involving allegations of inappropriate touching and an injury of unknown origin, the Provider Investigation Reports (Form 3613-A) were completed in the facility's electronic medical record system but were not submitted to the Texas Unified Licensure Information Portal (TULIP) within the required timeframe. The Assistant Director of Nursing (ADON), who was responsible for submitting these reports, believed the electronic system would automatically upload the reports, but later realized manual submission was necessary. The first two incidents involved a male resident with diagnoses including mood disorder, dementia, and high risk of heterosexual behaviors, who was alleged to have inappropriately touched two female residents. Both female residents had significant cognitive or physical impairments, including spina bifida, anxiety disorder, depressive episodes, diabetes, stroke, and aphasia. Immediate actions were taken by administration and clinical staff, and thorough investigations were completed, but the results were not timely reported to the State Survey Agency as required. The third incident involved a female resident with Alzheimer's disease, Parkinson's disease, and severe cognitive impairment, who sustained an injury of unknown origin resulting in a hip fracture and other medical complications. Although the investigation was completed and documented, the results were not uploaded to the TULIP system within the mandated 5-day period. Interviews with the ADON and Administrator confirmed the oversight and misunderstanding regarding the submission process, which led to the deficiency.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both sexual and physical abuse among residents. In one instance, a female resident with severe cognitive impairment and a history of traumatic brain injury was observed with her hand down the pants of a male resident, who was also severely cognitively impaired and diagnosed with schizophrenia and impulse disorder. The male resident held the female resident's hand in place and resisted staff intervention, requiring nursing staff to manually remove her hand. The care plans for both residents did not reflect updates or interventions addressing these sexual behaviors, despite prior incidents of inappropriate sexual conduct by the male resident, including exposing himself and masturbating in common areas, as well as inappropriate physical contact with another female resident who was also severely cognitively impaired and unable to communicate effectively. Additional incidents involved physical and verbal aggression between residents. One resident, with Alzheimer's disease and major depressive disorder, exhibited repeated aggressive behaviors, including hitting another resident on the hand with silverware, throwing coffee, making verbal threats, and physically striking other residents. These behaviors were documented in progress notes, but care plans were not updated to address the ongoing aggression or to provide interventions for the victims. In several cases, staff intervened to separate residents and de-escalate situations, but there was no evidence that these incidents were consistently reported to the abuse coordinator or that care plans were revised to reflect the risks and necessary supervision. The report also details failures in communication and documentation, such as not reporting certain abuse allegations to the state agency in a timely manner and lacking evidence of consent or capacity to consent in cases of alleged consensual sexual contact between cognitively impaired residents. Interviews with staff and family members confirmed awareness of behavioral issues and incidents, but also revealed gaps in monitoring, reporting, and care planning. The cumulative effect of these actions and inactions resulted in an Immediate Jeopardy finding, as the facility did not ensure residents' right to be free from abuse and neglect, and failed to implement adequate supervision, assessment, and care plan updates in response to repeated incidents.
Failure to Timely Report Alleged Abuse, Neglect, and Sexual Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or theft were reported immediately to the abuse coordinator and, when required, to the State Agency within the mandated timeframes. Multiple incidents involving resident-to-resident physical and sexual aggression, as well as verbal abuse, were not reported as required. In several cases, staff did not notify the abuse coordinator immediately after witnessing or being informed of abuse allegations, and several incidents were not reported to the State Agency within the required two-hour window for abuse or bodily injury, or within 24 hours for neglect. These failures were identified for seven out of ten residents reviewed for abuse. Specific events included a resident throwing coffee and threatening another, resulting in a physical altercation; a resident verbally abusing another, with threats of physical harm; and multiple instances of physical aggression, such as a resident hitting another with silverware and punching another resident in the chest. There were also incidents of sexual abuse, including a resident placing a hand down another resident's pants and a resident rubbing his private area against another resident. In each of these cases, documentation showed that the incidents were either not reported to the abuse coordinator or not reported to the State Agency within the required timeframe. Additionally, an incident of neglect involving a resident's unwitnessed fall with injuries was not reported to the State Agency within 24 hours. The residents involved had significant cognitive impairments, including diagnoses of Alzheimer's disease, dementia, major depressive disorder, and schizophrenia. Many required supervision or assistance for daily activities and had documented histories of behavioral symptoms such as aggression, inattention, and disorganized thinking. Despite these known risks, the facility did not update care plans to reflect new or ongoing aggressive or sexual behaviors following these incidents, nor did staff consistently follow established procedures for reporting abuse, neglect, or theft as required by regulation.
Failure to Update and Implement Comprehensive Care Plans Following Resident Incidents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans were not updated or revised to address significant changes in residents' conditions, including incidents of sexual and physical aggression, as well as abuse allegations. For example, one resident with schizophrenia, dementia, and impulse disorder exhibited repeated sexually inappropriate behaviors and aggression toward others, but the care plan was not updated to include interventions to prevent further incidents on several occasions. Another resident with Alzheimer's disease and major depressive disorder had multiple episodes of verbal and physical aggression toward other residents, including hitting and threatening, yet the care plan was not revised to reflect these behaviors or to implement new interventions after each incident. Several other residents who were victims of resident-to-resident aggression or abuse did not have their care plans updated to address their safety or to reflect the incidents they experienced. In one case, a resident was physically assaulted by another resident, but the care plan was not revised to include safety interventions. Another resident was subjected to inappropriate sexual behavior by a peer, but the care plan did not reflect this event or include measures to protect the resident. Additionally, a resident with significant cognitive impairment and multiple medical diagnoses was discharged before a comprehensive care plan was developed, despite the presence of a baseline care plan. Interviews with facility staff, including the ADON/MDS Coordinator, DON, and Administrator, revealed that care plan updates were delayed due to workload issues and staff covering multiple roles. Staff acknowledged that care plans should be individualized and revised promptly following incidents or changes in condition, but this was not consistently done. Facility policy required care plans to be developed within seven days of the MDS assessment and updated after significant changes, but these requirements were not met for several residents involved in incidents of aggression, abuse, or significant behavioral changes.
Removal Plan
- Care plans for residents 1 & 3 have been updated to include interventions to prevent abuse and manage behaviors by ADON/MDS nurse.
- ADON/MDS nurses have been in-serviced on when care plans are due and the importance of completing them in a timely manner by the Administrator.
- Administrator and DON will also monitor daily notifications from medical charting software for upcoming care plans due dates.
- MDS coordinator will submit weekly to DON and Administrator care plan list to indicate which care plans are due.
- DON has reviewed all care plans due dates and none are overdue.
- All residents had care plans reviewed by DON and after adjustments were made all care plans are now found to be accurate.
- All residents on secure unit were assessed by DON for injury and signs/symptoms of abuse and neglect.
- Care plan updates will be emailed by the ADON/MDS nurse to each nurses' station when a change occurs or a new focus is added such as but not limited to a change in behavior.
- The administrator will monitor for compliance by being copied on emails to nurse's stations.
- All charge nurses have been notified of this new system by DON.
- Nurses have been in-serviced by DON by cell phone on facility's policy and procedure for care plans and interventions.
- Staff were contacted and in-serviced by DON on abuse, neglect and exploitation, reporting suspected abuse, and intervention methods to include redirection.
- No staff will be allowed to work until this in-service is completed.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents who required oxygen management. Resident #1, a male with chronic obstructive pulmonary disease (COPD), was observed with an oxygen concentrator that lacked necessary air filters, and the areas meant to hold these filters were covered with a thick, dusty substance. This was despite his care plan indicating the need for oxygen at 2 liters per minute by nasal cannula when oxygen saturation fell below 92%. Resident #6, a female with lung cancer and congestive heart failure, was receiving oxygen at 4 liters per minute via nasal cannula. However, the filter on her oxygen concentrator was covered with a thick whitish substance. Interviews revealed confusion among staff about who was responsible for cleaning the filters, with the Maintenance Director believing it was the responsibility of the rental companies, and the ADON stating it should be done weekly by the night shift. Resident #39, a female with acute respiratory failure and heart failure, was also found with an oxygen concentrator filter covered in a thick, dusty substance. Despite her care plan requiring oxygen at 2 liters per minute as needed, the filters were not cleaned or replaced. Interviews with staff, including the DON and the Administrator, indicated that the responsibility for ensuring clean filters was not clearly assigned, leading to oversight and potential risk of decreased airflow to the concentrators.
Gas Stove Burner Malfunction in Kitchen
Penalty
Summary
The facility failed to maintain the gas stove in the kitchen in a safe operating condition, as observed on February 10, 2025, when one of the six burners did not light upon being turned on. The Dietary Manager (DM) noted that the burner had been functioning until that point and speculated that a pot might have splashed over, extinguishing the pilot light. The DM acknowledged responsibility for ensuring all kitchen equipment was operational and stated that staff were trained to report any equipment malfunctions to him or the Maintenance Director. The risk identified was that gas could escape if a knob was accidentally turned and the pilot light did not ignite immediately. Interviews with the Maintenance Director and the Administrator confirmed that the DM was primarily responsible for kitchen equipment maintenance, with the Maintenance Director serving as a backup. The Maintenance Director reported that all burners were functional during his last check on February 7, 2025, and suggested that grease might have clogged the pilot nozzle. He ordered a replacement part after being notified of the issue. The Administrator, who conducted weekly rounds, also confirmed that the burners were operational during his last inspection on February 2, 2025. Both the Maintenance Director and the Administrator emphasized the importance of staff reporting equipment issues promptly to ensure timely repairs.
Inaccurate MDS Coding for Insulin Use
Penalty
Summary
The facility failed to ensure accurate assessments for a resident, leading to an incorrect coding of the Minimum Data Set (MDS) for insulin use and injections. The resident, who was an elderly female with a history of hemiplegia, hypertension, and anxiety, did not have a diagnosis of diabetes mellitus nor any orders for insulin injections. Despite this, her quarterly MDS inaccurately indicated that she received insulin injections, which was not supported by her medical records or care plan. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON), confirmed that the resident had never received insulin or any type of injections. The ADON, who was responsible for completing the MDS, acknowledged the error and stated it would be corrected. The Director of Nursing (DON) also confirmed the incorrect coding and emphasized that such errors could lead to inappropriate resident care. The facility's policy on comprehensive assessments highlighted the importance of accurate coding to reflect the resident's clinical status, which was not adhered to in this case.
Inadequate Infection Control for Pleural Drain Bag
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper handling of a pleural drain bag for a resident with lung cancer, congestive heart failure, and high blood pressure. The resident, who had both long-term and short-term memory problems and was dependent on activities of daily living, was observed with their pleural drain bag and drain port on the floor under the bed. This observation was made despite the care plan indicating the need for enhanced barrier precautions related to the pleural drain. Interviews with facility staff, including an LVN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the pleural drain bag should not be on the floor to prevent infection and accidental dislodgement. The ADON, who also served as the infection control nurse, acknowledged the absence of a facility policy regarding the proper handling of pleural drain bags. The DON reiterated the expectation that the drain bag should be kept in a blue bag attached to the bed to prevent contamination. The lack of a formal policy and the improper placement of the drain bag on the floor represent a failure in the facility's infection control practices.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was at high risk for falls. The resident, who had Alzheimer's, dementia, restless leg syndrome, and Parkinson's, experienced an unwitnessed fall resulting in a 3 cm laceration above her right eye. The incident occurred because the fall mat, which was supposed to be adjacent to her bed, was not in place at the time of the fall. The resident's care plan, which was supposed to include interventions to prevent falls, did not list a fall mat as an intervention despite the resident's high risk for falls. The care plan was not updated to include the fall mat even after a previous fall incident where the resident was found lying on her fall mat with a minor injury. Staff interviews revealed that there was a miscommunication and oversight in updating the care plan to include the fall mat. Staff members, including a CNA and LVN, acknowledged that the fall mat was moved away from the bed to facilitate the movement of the resident's Geri-chair and was not repositioned when the resident was transferred back to bed. The facility's policies on safety and supervision, as well as managing falls and fall risk, emphasize the importance of implementing and documenting interventions to reduce accident risks, which were not adhered to in this case.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). On the specified date, the Administrator overheard CNA F making intimidating remarks to a resident, instructing them to get up in a loud and inappropriate manner. The Administrator witnessed the incident and identified the CNA as the individual responsible for the verbal abuse. The resident involved in the incident was an elderly female with a history of dementia and schizophrenia, which affected her ability to make decisions and communicate effectively. Her care plan indicated she required supervision and assistance with activities of daily living (ADLs) and was dependent on staff for emotional and physical needs. The resident exhibited behavioral problems, including resistance to care, which may have contributed to the situation. The facility's investigation confirmed the verbal abuse incident, and the CNA involved had been trained on abuse prevention and resident rights. Despite this training, the CNA admitted to raising her voice due to having a bad day, although she denied using the specific language reported. The facility's records showed that the CNA was suspended and subsequently terminated following the incident.
Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation and report the results of an incident involving a resident's fall within the required 5-day period. The resident, who had Alzheimer's, a right femur fracture, and a history of falling, experienced a fall in the lounge area. The fall was witnessed by staff, and the resident was subsequently sent to the emergency room for evaluation and treatment. Despite the incident being reported as neglect to the TULIP system, the facility did not complete an investigation or submit a 5-day report, as they believed the incident was not reportable due to it being witnessed. The Quality Assurance LVN and the Administrator both acknowledged that the report was made in error and attempted to have it deleted from the TULIP system. However, they did not follow up to ensure the report was actually removed. The facility's policy requires all reports of abuse, neglect, exploitation, or misappropriation to be thoroughly investigated and documented, but this was not adhered to in this case. The lack of investigation and reporting could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
Failure to Implement Comprehensive Fall Risk Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, who was at high risk for falls. The resident, diagnosed with Alzheimer's, dementia, restless leg syndrome, and Parkinson's, had a care plan that did not include the use of a fall mat, despite being at high risk for falls. This omission was evident in the care plan dated May 16, 2024, which listed several interventions but failed to mention the fall mat. The deficiency was highlighted by two incidents where the resident sustained injuries due to falls. On October 16, 2024, the resident was found lying on a fall mat with a small skin tear above her right eye, and on November 8, 2024, she was found on the floor with a 3 cm laceration above her right eye, requiring hospital treatment and sutures. Interviews with staff revealed that the fall mat was not consistently placed next to the resident's bed, contributing to the risk of injury. Interviews with facility staff, including the ADON, CNA, LVN, and the Administrator, confirmed that the care plan should have included a fall mat to prevent serious injuries. The staff acknowledged the oversight and the risk of serious injuries if fall mats were not in place. The facility's policies on safety, supervision, and care planning emphasized the importance of implementing and documenting specific interventions to reduce accident risks, which were not adhered to in this case.
Inadequate Supervision and Safety Measures for Smoking Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for residents who smoke, leading to a serious incident involving three residents. Resident #1, who was on oxygen therapy, was in a non-smoking area with Residents #2 and #3, both assessed as smokers. Resident #1's oxygen caught fire, resulting in multiple burns to her face, chest, and hands. The incident occurred because the residents were not in a designated smoking area, and there was no staff supervision present at the time. Resident #2 and Resident #3 were found to have kept smoking materials in their rooms, contrary to facility policy. Resident #2 was supposed to sign out his smoking supplies but did not comply, and staff were unaware of this non-compliance. Additionally, Resident #3 was not reassessed for smoking safety after the incident, and there was no updated Smoking-Safety Screen for either resident. The lack of proper assessments and supervision contributed to the unsafe conditions that led to the incident. Interviews with staff revealed a lack of awareness regarding which residents were smokers and who required supervision. There was no list of residents who smoked or required supervision, and staff were not consistently informed about residents' smoking statuses. This lack of communication and oversight resulted in residents smoking in non-designated areas without supervision, ultimately leading to the incident where Resident #1 sustained severe burns.
Failure to Ensure Smoking Safety Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to Federal, State, and Local laws and regulations regarding smoking safety, which resulted in a serious incident involving three residents. On the specified date, a resident who utilized oxygen was in a non-smoking area with two other residents who were assessed as smokers. The resident's oxygen caught on fire, leading to multiple burns on her face, chest, and hands. The facility did not ensure that the residents were smoking in a designated area, nor did they supervise the residents while they were smoking. Additionally, the facility failed to prevent residents from keeping smoking materials in their rooms. One resident admitted to keeping cigarettes and a lighter in his room, contrary to the facility's policy. The facility also did not reassess the residents for smoking safety after the incident, which was a critical oversight given the severity of the event. Interviews with staff revealed a lack of awareness regarding which residents were smokers and who required supervision, indicating a systemic failure in communication and policy enforcement. The incident highlighted the facility's inadequate smoking safety assessments and care planning. The residents involved had various medical conditions, including COPD and cognitive impairments, which should have necessitated stricter supervision and safety measures. The facility's failure to maintain up-to-date smoking safety assessments and care plans contributed to the unsafe environment that led to the incident.
Failure to Implement Comprehensive Smoking Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs. Resident #1, a female with severe cognitive impairment and on oxygen therapy, did not have a care plan addressing tobacco use or smoking safety, despite being observed smoking a vape pen and attempting to smoke a cigarette while on oxygen. This oversight placed her at risk for unsafe smoking practices. Resident #2, a male with cognitive intactness, had a care plan for smoking that was not reviewed or updated when he refused to comply with the facility's smoking policy. He did not sign out to smoke off facility grounds and kept his smoking supplies in his room, contrary to the policy that required supervision and storage of smoking supplies at the nurses' station. The lack of updated assessments and care plans contributed to the staff's unawareness of his smoking habits and supervision needs. Resident #3, a female with cognitive intactness, had a care plan for smoking that was not updated after she was found with cigarettes and a lighter. Staff interviews revealed a lack of awareness regarding which residents smoked and their supervision requirements. The facility's failure to maintain a list of smokers and conduct regular smoking assessments led to inadequate supervision and increased the risk of unsafe smoking practices among residents.
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.
