Sienna Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Odessa, Texas.
- Location
- 2510 W 8th Street, Odessa, Texas 79763
- CMS Provider Number
- 675928
- Inspections on file
- 32
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 6 (3 serious)
Citation history
Health deficiencies cited at Sienna Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with dementia, diabetes, and pre-existing protein-calorie malnutrition experienced an 11.47% weight loss over approximately three months while on a regular diet and requiring only setup assistance for eating. Although a weight-loss assessment identified significant weight loss and listed interventions such as a red cup program and high-calorie supplements, these were not entered as MD orders, the resident was not placed on the red cup list, and supplements were not ordered until mid-way through the second month. The RD’s admission recommendation for house supplements three times daily was not converted into active orders, the RD did not receive accurate weight-loss reporting, and the NP was not notified of the significant weight change. Observations showed poor meal intake and lack of consistent offering of alternatives or supplements, while staff interviews revealed unawareness of the resident’s weight loss and confusion over who monitored the red cup program. These failures to follow the facility’s weight policy, to monitor and communicate significant weight changes, and to implement ordered or recommended nutritional interventions resulted in the resident’s continued weight decline.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral issues engaged in physical altercations, resulting in injuries such as head lacerations and skin tears. Despite being identified as needing 1:1 supervision, residents were not provided with dedicated staff, and existing CNAs were expected to cover both general care and 1:1 monitoring. Staff interviews and records confirmed that required supervision was not maintained, directly leading to resident-to-resident abuse and injuries.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral issues engaged in physical altercations, resulting in injuries such as head lacerations and skin tears. Despite care plans and facility protocols requiring 1:1 monitoring, staffing records and staff interviews confirmed that no additional staff were assigned for this purpose, and existing CNAs were expected to rotate 1:1 monitoring duties while supervising the entire unit. This lack of adequate supervision led to repeated resident-to-resident altercations and injuries.
Multiple incidents occurred where residents with severe cognitive impairment and behavioral risks did not receive required 1:1 monitoring due to insufficient staffing. Existing CNAs were expected to supervise large numbers of residents and provide 1:1 monitoring simultaneously, leading to unsupervised periods and resulting in altercations and injuries. Staff interviews and records confirmed that no additional staff were assigned for 1:1 monitoring, and the facility lacked a formal staffing policy.
The DON worked as a charge nurse on multiple occasions when the facility census was 60 or more, contrary to regulatory requirements. The DON reported covering night shifts due to a staff vacancy and was unaware of the regulation prohibiting this practice. No policy for RN/DON coverage was provided when requested.
The facility did not update or revise care plans for three residents with severe cognitive impairment after multiple documented incidents of aggression and wandering, despite repeated behavioral episodes that required staff intervention and hospital transfers. Care plans had not been revised to include new interventions following these events, contrary to facility policy and standard practice.
Staff at the facility were observed using personal cell phones in the presence of residents, violating their rights to dignity and respect. Residents reported feeling disrespected and ignored, with staff using phones while providing care and passing medications. Despite facility policies prohibiting such behavior, the issue persisted, indicating a failure to enforce these rules effectively.
A facility failed to restrict access to its medication room, allowing unauthorized personnel, such as a Medical Records staff member and Central Supply staff, to enter and be alone in the room. This breach of protocol, observed during a survey, involved the use of a code to unlock the room, which contained various medications and medical supplies. The facility's policy mandates that only authorized personnel should have access to the medication supply.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) for residents requiring such measures. CNAs did not use PPE during incontinent care and transfers for residents on EBP, and there was a lack of accessible PPE in resident rooms. Staff interviews revealed a breakdown in communication and understanding of EBP requirements, contributing to the risk of cross-contamination and infection spread.
A facility failed to label a Mid-line IV dressing with the date and initials, as required by policy, for a resident with chronic kidney disease and other conditions. The resident's dressing was intact but lacked labeling, which is necessary for monitoring changes and preventing infections. The DON confirmed the expectation for labeling to reduce infection risks.
A resident's shower log was inaccurately documented, showing multiple refusals of showers despite interviews indicating the resident never refused. Staff admitted to a possible documentation error, which could lead to inadequate care. The facility's policy requires accurate documentation, which was not followed in this instance.
A facility failed to accurately receive and store controlled medications for a resident, leading to the diversion of Alprazolam tablets. The resident, with multiple diagnoses including dementia and anxiety, was on hospice care. The medications were delivered by a hospice nurse without proper documentation or signature, and the DON was the last to have contact with them. Facility policies for securing and documenting controlled substances were not followed.
A resident's Tramadol was not secured in a double-locked area as required, leading to an investigation. The medication was delivered by a hospice nurse without obtaining a signature, and the DON, who was the last to see the medications, did not recall the specifics due to fatigue. The facility's policies for handling controlled substances were not followed, resulting in a breakdown in procedure adherence.
The facility failed to implement its QAPI plan, resulting in deficiencies in addressing adverse events for four residents. A resident repeatedly exhibited aggressive behaviors towards another, but the facility did not complete incident/accident reports, hindering behavior tracking. Additionally, two other residents demonstrated physical behaviors without proper documentation. Interviews revealed inconsistent tracking due to incomplete reports, impacting the facility's quality assurance processes.
The facility failed to follow professional standards for food service safety, resulting in improper food storage, cross-contamination risks, and inadequate use of hair restraints. Observations showed food stored beyond recommended periods, items on the floor, and improper thawing practices. Staff interviews confirmed these practices, and the facility's policies were not adhered to, posing potential risks to residents.
The facility failed to maintain essential kitchen equipment, including the oven, garbage disposal, and milk refrigerator, in safe operating condition. Observations revealed issues such as a rusted hinge and detached gasket on the refrigerator, a non-functional garbage disposal, and an oven that did not reach the required temperature. Staff acknowledged these problems, but no work orders were provided, and the Administrator was unaware of the issues.
A facility failed to update a care plan for a resident with a history of crawling behavior, leading to knee abrasions. Despite awareness of the behavior, the care plan lacked specific interventions, and video surveillance confirmed the resident's crawling and subsequent injuries. The resident was placed in a low bed with a floor mat, but no additional measures were taken to prevent injury.
A resident with a history of crawling behavior was not provided with adequate supervision or assistive devices, leading to injuries. Despite being aware of the behavior, the facility did not revise the care plan to include interventions. The resident sustained abrasions and reopened wounds on her knees, as documented in progress notes and observed in video surveillance. Staff interviews confirmed awareness of the behavior but not of specific incidents or injuries.
Failure to Implement and Coordinate Nutritional Interventions for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident maintained acceptable parameters of nutritional status, as evidenced by an 11.47% weight loss over 80 days without timely and fully implemented interventions. The resident was an elderly female admitted with diagnoses including protein-calorie malnutrition, diabetes mellitus, dementia, and anxiety disorder. Her admission MDS showed severe cognitive impairment (BIMS score of 2), a regular diet, and no documented weight loss or physician-ordered weight-loss program. Her care plan, revised in early December, identified her as at risk for malnutrition with interventions such as determining food preferences, monitoring and documenting intake, monitoring weight per facility protocol, serving the ordered diet, and notifying the physician of negative findings. Weight records showed an active decline from early December through mid-February, with the resident’s weight decreasing from 191.8 pounds to 169.8 pounds. A nutrition assessment by the RD in mid-December documented a weight of 185.6 pounds, a regular diet and texture, and food intake ranging from 25–100%. A weight watchers’ assessment in mid-January identified a 14.4‑pound weight loss and listed interventions of a red glass and a 2‑calorie supplement with each med pass. However, the resident did not appear on the facility’s red cup program list, and there were no corresponding physician orders in January for supplements or the red glass program. In February, no supplement order was present until mid-month, when Boost twice daily was ordered; there was still no physician order for the red glass program. Observations and interviews further demonstrated that the identified interventions were not consistently implemented or communicated. During lunch observations on consecutive days in February, the resident took only a few bites of food, repeatedly left the table, and on one day accepted a supplement, while on another day no alternative or supplement was observed being offered. The Dietary Manager stated she was responsible for the red glass program notifications but was unaware of the resident’s weight loss and confirmed the resident was not on the snack list. The new DON reported she had only recently become aware of the weight loss, implemented a supplement order mid-February, and believed the resident should have had weekly weights, supplements, and placement on the red glass program. The ADON acknowledged completing a weight watcher assessment in mid-January and intending to initiate the red glass program and 2‑calorie supplements with each med pass but admitted she forgot to enter these as physician orders. The RD stated she had recommended house supplements three times daily on admission and that these should have been entered as physician orders, but the resident did not appear on the January weight loss report. The NP reported she was unaware of the extent of the weight loss and had not been notified. These actions and inactions occurred despite a facility policy requiring review of significant weight changes, documentation on weight watcher forms with interventions, physician and family notification, initiation of an acute care plan for weight loss, and RD assessment and recommendations for significant weight loss. The facility’s own policy defined significant weight loss thresholds and required that such changes be recorded on a weight watchers’ form with interventions and follow-up, that the physician and family be notified, and that an acute care plan for weight loss be initiated. It also required referral of all significant weight changes to the Regional Dietitian for assessment and review of interventions. In this case, although a weight watchers’ assessment was completed and interventions were listed, they were not converted into active physician orders, the resident was not placed on the red glass program list, and the RD did not receive accurate weight loss reporting in January. Staff interviews showed inconsistent awareness of the resident’s weight loss and program status, and the NP was not informed of the significant weight change. These documented failures to follow policy and to implement and coordinate ordered or recommended nutritional interventions contributed directly to the resident’s continued weight decline. Throughout this period, meal intake documentation for January and February continued to show 25–100% consumption, while direct observations showed poor intake and difficulty remaining at the table. CNAs and nursing staff reported offering alternatives and snacks generally, but the assigned CNA confirmed the resident was not on the red cup program, which was supposed to trigger extra attention to intake. The DON, ADON, RD, and NP each described gaps in communication and follow-through regarding weight monitoring, program placement, and supplement orders. Collectively, these documented lapses in monitoring, communication, and implementation of nutritional interventions led to the resident’s significant, ongoing weight loss and constituted the cited deficiency in maintaining acceptable nutritional status.
Failure to Provide Sufficient Staffing and 1:1 Monitoring Resulting in Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically by not providing sufficient staffing and failing to implement required 1:1 monitoring for residents with known behavioral risks. Multiple incidents occurred in both male and female secured locked units, where residents with severe cognitive impairment and behavioral diagnoses engaged in physical altercations resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be under 1:1 supervision were not provided with a dedicated staff member, as required by the facility's own in-service training and policy. On multiple occasions, staff assignments did not include additional personnel for 1:1 monitoring, despite residents being identified as needing such supervision due to aggressive or violent behaviors. For example, one male resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident, causing a head injury that required emergency room treatment and staples. Another incident involved a resident slapping and injuring a peer while supposed to be under 1:1 monitoring, but no extra staff was assigned, and the monitoring was performed by staff already responsible for the entire unit. Similar failures occurred in the female secured unit, where a resident with traumatic brain injury and dementia physically assaulted two other residents, causing skin tears and facial injuries, again without the required 1:1 supervision being provided. Interviews with staff and review of staffing schedules confirmed that the facility routinely failed to assign additional staff for 1:1 monitoring, instead expecting existing CNAs to rotate or cover both general care and 1:1 supervision, even during night shifts when staffing was further reduced. Staff reported being unable to maintain arm's-length supervision as required, and monitoring sheets were often signed by staff who were simultaneously responsible for multiple units or entire halls. These actions and inactions directly led to resident-to-resident altercations and injuries, as documented in progress notes, investigation reports, and staff interviews.
Failure to Provide Adequate Supervision and 1:1 Monitoring Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, specifically in relation to resident-to-resident altercations on two secured units. Multiple incidents occurred where residents with known behavioral issues and severe cognitive impairment engaged in physical altercations, resulting in injuries such as head lacerations, skin tears, and hospitalizations. In several cases, residents who were supposed to be on 1:1 monitoring did not have a designated staff member assigned to them, as required by the facility's own in-service training and staffing protocols. Instead, existing staff were expected to rotate or cover 1:1 monitoring in addition to their regular duties, leading to lapses in supervision. On the male secured locked unit, one resident with a history of explosive disorder and severe cognitive impairment physically assaulted another resident who had wandered into his room, causing a head injury that required emergency room treatment and staples. The same resident later assaulted a different resident, resulting in a fall and a skin tear. Despite care plans indicating the need for 1:1 supervision, staffing records and interviews confirmed that no additional staff were assigned for this purpose, and the two CNAs on duty were responsible for supervising all residents on the unit as well as providing 1:1 monitoring. Staff interviews corroborated that it was common practice for no extra staff to be provided for 1:1 monitoring, even when required. Similar deficiencies were observed on the female secured unit, where a resident with traumatic brain injury and severe cognitive impairment physically assaulted two other residents, causing skin tears and facial injuries. Again, although 1:1 monitoring was indicated after the first incident, staffing records showed that only one CNA was present for the entire unit, and no additional staff were assigned for 1:1 monitoring. Staff interviews revealed that it was rare for a third CNA to be sent for 1:1 monitoring, and that CNAs often had to rotate the responsibility among themselves while still supervising the rest of the unit. The lack of adequate supervision and failure to follow established protocols for 1:1 monitoring directly contributed to repeated resident-to-resident altercations and injuries.
Failure to Provide Sufficient Staffing and 1:1 Monitoring in Secure Units
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in the secure male and female units, resulting in multiple resident-to-resident altercations and injuries. On several occasions, residents who required 1:1 monitoring due to behavioral risks did not have a designated staff member assigned to them, as required by the facility's own in-service training and stated procedures. Instead, existing CNAs were expected to rotate or attempt to monitor these residents in addition to their regular duties, despite being responsible for large numbers of residents with known behavioral issues. This lack of dedicated staffing led to incidents where residents were left unsupervised, resulting in physical altercations, falls, and injuries such as skin tears and lacerations. Specific incidents included a male resident with severe cognitive impairment and a history of physical aggression who was placed on 1:1 monitoring after an altercation, but no additional staff was assigned. This resident subsequently assaulted another resident, causing a fall and injury, while unsupervised in the dining room. Similarly, in the female secure unit, a resident with a traumatic brain injury and severe cognitive impairment was involved in multiple altercations, including grabbing and slapping other residents, while supposed to be on 1:1 monitoring. Staffing records and interviews confirmed that no extra staff were provided for 1:1 monitoring during these times, and CNAs reported being unable to maintain required supervision due to being the only staff on the unit or having to cover both secure units simultaneously. Interviews with staff, including CNAs and nurses, revealed that it was common practice for the facility to operate with fewer staff than required, especially during night shifts, and to rely on existing staff to provide 1:1 monitoring without relief. The Director of Nursing and Assistant Director of Nursing acknowledged that additional staff should be assigned for 1:1 monitoring but were unaware of instances where this did not occur. The facility did not have a formal staffing policy, and documentation showed that 1:1 monitoring sheets were often signed by staff already assigned to the unit, rather than by a dedicated monitor. These failures were confirmed through observation, record review, and staff interviews.
DON Served as Charge Nurse During High Census
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the average daily occupancy was 60 or more residents, as required by regulation. Review of the daily staffing schedule showed that the DON worked as a charge nurse on nine separate days during the review period. During an interview, the DON confirmed she had been working night shifts as the charge nurse due to a recent staff resignation and stated that no one else had been designated to perform her DON duties during these times. The DON also indicated she was unaware of the regulation prohibiting her from working the floor in this capacity. Additionally, when requested, the facility was unable to provide a policy for RN/DON coverage. The job description for the DON emphasized the need for knowledge of nursing home regulations and accountability for compliance, but also included a provision to augment floor staffing if needed. There were no details provided about specific residents or their conditions related to this deficiency.
Failure to Update Care Plans After Behavioral Incidents and Assessments
Penalty
Summary
The facility failed to review and revise comprehensive care plans by the interdisciplinary team after each assessment for three residents. Specifically, the care plans were not updated to reflect new or ongoing behavioral issues, such as aggressive and physical behaviors towards other residents and wandering, despite documented incidents in the residents' progress notes. The care plans for these residents had not been updated with new interventions since their last revisions, even though there were multiple documented episodes of aggression and wandering that required staff intervention and, in some cases, resulted in hospital transfers. One male resident with severe cognitive impairment and a history of explosive disorder exhibited repeated aggressive behaviors, including hitting and shoving other residents, which led to another resident being sent to the emergency room. Despite these incidents, his care plan had not been updated with new interventions since the previous year. Another female resident with traumatic brain injury and dementia also demonstrated physical aggression, such as grabbing and slapping other residents, but her care plan interventions had not been revised since the previous year, even after multiple aggressive episodes were documented. A third male resident, also with severe cognitive impairment and a history of explosive disorder, was involved in a resident-to-resident altercation after wandering into another resident's room, resulting in a fall and injury. His care plan, which addressed wandering, had not been updated with new interventions since his admission, despite these incidents. The Director of Nursing confirmed that care plans should be updated after such events but was unable to explain why this had not occurred. Facility policy requires care plans to be reviewed and revised after each assessment and in response to changes in the resident's condition or interventions.
Staff Cell Phone Use Violates Resident Dignity
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect, as evidenced by staff members using personal cell phones in the presence of residents. This behavior was observed during a confidential group interview with 11 residents, who reported feeling disrespected and ignored. The residents expressed concerns that staff were frequently on their phones, even while providing care, passing medications, and ignoring call lights. This led to feelings of discomfort and the perception that staff did not care about them. The issue was reported multiple times in Resident Council Meetings, with residents noting that staff conversations were often personal and inappropriate. The facility's policy prohibits the use of personal communication devices during work hours, except during breaks, and explicitly forbids the use of cell phones in residents' presence. Despite this policy, the Activity Director was observed using a cell phone in the main dining room, and residents reported that staff were on their phones while providing care. Interviews with the ADON, DON, and RN Consultant revealed that they were unaware of the extent of the issue, although they acknowledged the policy and the potential for privacy violations. The facility had conducted in-services on phone use, but the problem persisted, indicating a failure to enforce the policy effectively.
Unauthorized Access to Medication Room
Penalty
Summary
The facility failed to ensure that only authorized personnel had access to the medication room, which was reviewed for drug storage. During an observation, it was noted that a Medical Records staff member, who was unauthorized to be in the medication room unattended, had access to the room. The staff member unlocked the medication room using a code and was present in the room without any nursing staff. The room contained various medications, including over-the-counter and prescribed drugs, as well as insulin and other medical supplies. Interviews revealed that the Medical Records staff member often stocked the medication room with over-the-counter medications and was sometimes left alone in the room when the nurse stepped out. Additionally, the Central Supply staff member also had access to the medication room and had been in the room alone to stock it. The facility's policy indicated that only licensed nursing personnel, pharmacy personnel, or staff members authorized to administer medications should have access to the medication supply. This breach in protocol could potentially lead to drug diversion.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, CNAs A, B, E, and D did not use personal protective equipment (PPE) during incontinent care for residents on EBP, such as Residents #17 and #60. CNA B, in particular, did not change her gloves after they became contaminated during care for Resident #17, and neither CNA A nor B wore gowns during the procedure. Additionally, CNAs C, D, E, and F did not use PPE during transfers for EBP residents, including Residents #49, #60, and #67. For instance, CNA C and CNA D assisted Resident #49 with a transfer without wearing gowns, despite the resident being on EBP due to a past diagnosis of an antibiotic-resistant infection. Similarly, CNA E and CNA D performed incontinent care and a transfer for Resident #60 without gowns, even though there was a sign indicating EBP was required. The facility's failure to ensure proper use of PPE and adherence to EBP protocols was further highlighted by the lack of accessible PPE in resident rooms and the staff's lack of awareness regarding which residents were on EBP. Interviews with staff, including the ADON, revealed a breakdown in communication and understanding of EBP requirements, contributing to the risk of cross-contamination and infection spread among residents.
Failure to Label IV Dressing
Penalty
Summary
The facility failed to ensure the proper administration of intravenous (IV) fluids for a resident, specifically by not adhering to professional standards regarding the labeling of a Mid-line intravenous line dressing. The resident, a female with chronic kidney disease, type 2 diabetes, and pressure ulcers, was admitted to the facility with a Mid-line IV for administering fluids and medications. The dressing on the resident's Mid-line IV was observed to be intact but lacked the required date and initials, which are essential for monitoring dressing changes and preventing infections. The resident was unable to recall when the Mid-line was inserted or when the dressing was last changed. The Director of Nursing (DON) confirmed that the facility's policy mandates that IV dressings be labeled with the date, time, and initials to track dressing changes and minimize infection risks. The facility's policy on dressing changes explicitly requires this labeling, yet the observation and record review revealed non-compliance with this standard. The absence of labeling on the dressing could potentially place residents at risk for infections, although no signs of infection were noted at the time of observation.
Inaccurate Documentation of Resident's Shower Log
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately documented for a resident whose assessments were reviewed. Specifically, the shower log for the resident inaccurately documented that the resident refused showers on multiple occasions, despite interviews indicating that the resident never refused showers. The resident, a male with diagnoses including Dementia, Malnutrition, and obstructive pulmonary disease, was supposed to receive showers on specific days, but the log incorrectly noted refusals. Interviews with staff and another resident revealed that the resident consistently received showers and never refused them. A staff member admitted to possibly mis-clicking on the documentation, leading to the incorrect recording of shower refusals. The Assistant Director of Nursing confirmed that this was a documentation error, which could potentially lead to inadequate care due to inaccurate records. The facility's policy requires complete and accurate documentation for each resident, which was not adhered to in this case.
Failure to Secure and Document Controlled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of controlled medications for a resident. Specifically, the facility did not accurately receive and store 45 tablets of Alprazolam, an anti-anxiety medication, and 60 tablets of Tramadol, a pain medication, both classified as Schedule IV narcotics. This failure resulted in the diversion of the Alprazolam tablets. The resident involved was an elderly male with multiple diagnoses, including dementia with behavioral disturbance, hypertension, depression, anxiety, and a psychotic disorder with delusions. He was living in a secured unit and receiving hospice services. The resident's care plan included the use of anti-anxiety medications to manage his symptoms, and he had a prescription for Alprazolam to be administered twice daily and as needed. The deficiency was identified when a Licensed Vocational Nurse (LVN) discovered that the Alprazolam medication card was missing from the medication cart. The facility's investigation revealed that the medications were delivered by a hospice nurse, but there was no signature or confirmation of receipt. The Director of Nursing (DON) was reportedly the last person to have contact with the medications, but she did not recall handling them. The facility's policies required controlled substances to be stored under double lock and documented with a narcotic count sheet, which was not followed in this instance.
Medication Storage Deficiency in LTC Facility
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to medications, specifically for one of the four medication carts reviewed. This deficiency was highlighted by the case of a resident whose 60 tablets of Tramadol were not secured in a double-locked area, as required for controlled substances. The Tramadol was delivered by a hospice nurse and was later found missing, leading to an investigation by the facility. The investigation revealed that the Tramadol was delivered by a hospice nurse who did not obtain a signature upon delivery, and the medication was allegedly left in the medication room instead of being secured in the medication cart's locked drawer. The Director of Nursing (DON) was identified as the last person to have seen the medications, but due to working multiple shifts and being tired, the DON did not recall the specifics of the delivery or handling of the medications. The Assistant Director of Nursing (ADON) and other staff members expressed concerns about the lack of proper procedures followed during the delivery and storage of the medications. Interviews with various staff members, including the Administrator, ADON, and MDS Coordinator, indicated a breakdown in communication and procedure adherence. The hospice nurse admitted to not having the DON sign for the medications and mentioned the chaotic environment on the day of delivery. The facility's policies and procedures for handling controlled substances were not followed, as the Tramadol was not placed in the narcotic box with a count sheet, and the delivery process lacked proper documentation and accountability.
Failure to Implement QAPI Plan and Document Incidents
Penalty
Summary
The facility failed to implement its Quality Assessment and Performance Improvement (QAPI) plan, which led to deficiencies in addressing adverse events related to potential deficient practices for four residents. The facility did not identify a pattern of behaviors between two residents, where one resident repeatedly exhibited aggressive behaviors towards another over a six-month period. Despite multiple incidents, including hair-pulling and physical aggression, the facility did not complete incident/accident reports, which hindered the ability to track and trend these behaviors effectively. Additionally, the facility failed to complete incident/accident reports for two other residents who demonstrated physical behaviors. One resident exhibited aggressive behaviors such as attempting to hit others and making false accusations, while another resident engaged in behaviors that could lead to altercations, such as shaking other residents' wheelchairs. The lack of documentation and reporting of these incidents prevented the facility from identifying patterns and implementing appropriate interventions. Interviews with facility staff revealed a lack of consistent tracking and trending of behaviors due to incomplete incident/accident reports. The facility relied on morning meetings to discuss behaviors, but without proper documentation, it was challenging to identify patterns or trends. The facility's policy required incident/accident reports for behaviors affecting others, but this was not consistently followed, leading to deficiencies in the facility's quality assurance processes.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, leading to several deficiencies. Observations revealed that food was not stored properly, with items such as pudding, garbanzo beans, and black olives being kept beyond the recommended seven-day period. Additionally, pasteurized eggs, tea, and water were stored on the floor of the walk-in refrigerator, which is against food safety protocols. A tube of ground beef was found thawing without a pan, resulting in a puddle of blood on the floor, indicating improper thawing practices. The facility also failed to prevent cross-contamination during food preparation. Cook A was observed changing gloves multiple times without washing or sanitizing her hands after touching the trash can lid, which could lead to contamination. Furthermore, dietary aides were not using effective hair restraints, with one aide's beard partially uncovered and another aide's hair partially exposed. The pots and dishes were stored face up and uncovered, leaving them susceptible to airborne contamination. Interviews with the Dietary Manager (DM) and staff confirmed these practices, with the DM acknowledging the improper storage and handling of food items. The DM also admitted that the hairnets used were ineffective and that there was no explanation for the eggs being stored on the floor. The facility's policies and procedures, dated 2012, were reviewed and found to be in place to prevent such deficiencies, but they were not being followed, leading to potential risks of foodborne illness and cross-contamination for residents receiving meals from the kitchen.
Facility Fails to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, which included the oven, garbage disposal, and milk refrigerator. Observations revealed that the milk refrigerator had a rusted hinge and a detached, black gasket, which compromised its sealing ability. The garbage disposal was non-functional, and the oven failed to reach the required temperature during meal preparation. These issues were observed over several days, with staff acknowledging the problems but no immediate corrective actions were evident. Interviews with the Dietary Manager (DM) indicated that the garbage disposal had been non-functional for two weeks, and the refrigerator issues had persisted for over a year. The DM had informed the maintenance director about these issues, but no work orders were provided to substantiate these claims. The DM also mentioned that the oven's temperature gauge had been replaced, but it still failed to reach the correct temperature intermittently. The Administrator and Regional Compliance Officer were unaware of these issues, indicating a communication breakdown within the facility.
Failure to Revise Care Plan for Crawling Behavior
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident who exhibited crawling behavior, which was not addressed in her care plan. The resident, a female with multiple diagnoses including seizures, developmental disorder of speech and language, and schizophrenia, was admitted with a history of crawling behavior. Despite this, the care plan did not include interventions for this behavior, even though it was documented in progress notes multiple times over the course of a year. The resident was placed in a low bed with a floor mat due to poor safety awareness, but no specific interventions were in place to address the crawling behavior. The deficiency was highlighted when the resident sustained abrasions to her knees from crawling, which were documented in progress notes. Interviews with the resident's responsible party and facility staff revealed that the facility was aware of the behavior but had not implemented additional interventions to prevent injury. Video surveillance confirmed the resident's crawling behavior and subsequent injuries. The facility's failure to update the care plan to include interventions for the resident's crawling behavior placed her at risk of injury.
Failure to Prevent Injuries from Crawling Behavior
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for a resident with a known crawling behavior. The resident, a female with multiple diagnoses including seizures and schizophrenia, was admitted with a history of crawling behavior. Despite this, her comprehensive care plan did not include interventions for this behavior. The resident was placed in a low bed with a floor mat due to poor safety awareness, but no additional measures were implemented to address her crawling. The resident's progress notes documented her crawling behavior on multiple occasions, leading to abrasions and reopened wounds on her knees. Staff interviews revealed that the facility was aware of the behavior but not of specific incidents or injuries. Video surveillance showed the resident crawling and walking in the hallway, refusing staff assistance, and becoming aggressive. The facility's lack of intervention and supervision resulted in the resident sustaining injuries, highlighting a deficiency in ensuring a safe environment.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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