Signature Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 14655 Preston Rd, Dallas, Texas 75254
- CMS Provider Number
- 675757
- Inspections on file
- 41
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Signature Pointe during CMS and state inspections, most recent first.
A resident with depression, anxiety, and dementia, but assessed as cognitively intact, was moved from one floor to another Medicaid-designated room without the facility providing written notice or the reason for the move to the resident’s designated Resident Representative (RR), who held medical power of attorney. Staff had the resident sign a room change notification form, even though he was not his own Responsible Party, and he reported feeling coerced and not understanding why he was being moved. The RR stated she only learned of the move when the resident called her and that the facility did not notify her. The Administrator and CNO reported they believed informing the resident alone was sufficient if the resident was coherent and indicated they relied on the resident to notify the RR, despite facility policy stating that RR decisions are treated as the resident’s decisions.
A resident with dementia and depression, but assessed as cognitively intact, was prescribed PRN Tramadol for pain without notifying the designated Resident Representative (RR), despite admission documents showing the RR had consented to treatment and the facility’s policy defining the RR as a person to receive notifications. The RR later reported she had not been informed of the narcotic prescription and expressed concern due to the resident’s history as a recovering alcoholic. The Administrator and CNO stated they believed notification was unnecessary because the resident was coherent and able to make his own decisions, while the DON and ADON were unsure if RR consent was required but acknowledged they typically tried to keep the RR informed.
Two residents who were totally dependent for ADLs did not consistently receive required hygiene and grooming care. A male resident with hemiplegia and a contracted hand had excessively long, dirty fingernails for weeks despite repeated requests by him and his representative, and his grievance about nail care was not addressed in a timely manner. A female resident with hemiplegia, physical debility, and severe cognitive impairment, care planned as at risk for skin breakdown, reported that bed baths were not provided consistently and that she had not refused them, while her record initially contained only one uploaded shower form before additional bath records were later produced. Staff interviews showed that CNAs were expected to provide showers/bed baths and nail care and that charge nurses, the ADON, and the DON were responsible for ensuring completion and documentation of these ADL services in accordance with facility policy.
Three residents with severe cognitive impairment and significant physical limitations did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed that procedures to check and secure call lights were not consistently followed, resulting in residents being unable to request assistance when needed.
A nurse left a cart unattended in a hallway with a paper listing several residents' vital signs and an open laptop displaying their names, photos, and care levels. This information was visible to unauthorized staff and others passing by, violating facility policy on confidentiality and privacy of protected health information.
Multiple instances were observed where medicated ointments and wound cleansers were left unsecured in resident rooms, and a solution for a breathing treatment was left unattended on a nurse's cart. Staff interviews confirmed that these medications should have been stored in locked compartments and not accessible to residents, in accordance with facility policy.
Staff failed to follow infection control protocols during care for two residents, including not performing hand hygiene between glove changes during incontinent care and not wearing a gown as required under Enhanced Barrier Precautions when disconnecting an IV. These lapses occurred despite staff awareness of facility policies and posted reminders.
A resident with a gall bladder tube was found with her drainage bag uncovered and in public view, despite physician orders and facility policy requiring it to be covered for privacy and dignity. Multiple staff members, including an ADON, LVN, and DON, acknowledged the oversight and confirmed that the bag should have been concealed to maintain the resident's dignity.
Three residents with significant cognitive and physical impairments were found with their nurse call lights on the floor and out of reach while in bed, despite care plans and facility policy requiring call lights to be accessible. Staff confirmed the expectation that call lights should be within reach, but this was not maintained during the survey.
Two residents were found using bolster mattresses as physical restraints without required physician orders or proper care plan documentation. Staff confirmed that physician orders were necessary for these devices, but none were present in the records, contrary to facility policy.
A resident with acute respiratory failure who required regular nebulizer treatments was found to have her nebulizer mask left unbagged in her nightstand after use, in violation of facility policy and professional standards. The LVN responsible admitted to forgetting to bag the mask, and the DON confirmed the lapse in infection control practice.
A resident with severe cognitive impairment and bilateral hand contractures was not provided with an accessible call light system. The call light was out of reach, and staff had not assessed the resident's ability to use the standard or alternative call light options, as required by facility policy. This resulted in the resident lacking a suitable means to request assistance.
A resident with severe cognitive impairment and mobility issues was found in bed with bolster pads on all sides, preventing free exit. The use of these pads was not included in the care plan and lacked physician orders, despite facility policy requiring such authorization for restraints. Staff were unaware that orders were needed for this equipment.
A nurse left a piece of paper containing the names, vital signs, and blood sugar readings of five residents exposed and unattended on a nurse's cart in a hallway, making confidential medical information visible to unauthorized individuals. Facility leadership confirmed this was a violation of privacy and confidentiality policies.
Three residents requiring oxygen therapy had their nasal cannulas improperly stored when not in use, with devices left on beds, floors, or tables instead of being bagged as required. Staff and documentation confirmed that proper infection control procedures were not followed, despite physician orders and care plans specifying the need for continuous oxygen and safe storage of respiratory equipment.
A wound care cart containing medications and biologicals was found unlocked and unattended in a hallway near the rehabilitation department, with its drawers easily accessible to residents and staff. The DON, ADON, and Administrator confirmed the cart should have been locked when not in use, in accordance with facility policy.
The facility's kitchen failed to meet food safety standards, with staff not wearing proper hair coverings, improper food storage, and unclean equipment. Observations included uncovered trash cans, dirty storage bins, and expired food not discarded. The Dietary Manager and Executive Director were aware of these issues but had not yet addressed them.
A resident with rheumatoid arthritis and physical debility was found with an outdated wound dressing on her elbow, with no physician order documented. The wound care nurse, returning from leave, discovered the issue and contacted the doctor for proper orders. The use of agency nurses during the nurse's absence led to a lack of awareness about the dressing, risking infection due to non-compliance with the facility's wound care policy.
The facility failed to ensure proper infection control in respiratory care for two residents. A resident's CPAP hose was found on the floor, posing a contamination risk, while another resident's nasal cannula was left unbagged and balled up on the floor. Both instances were identified as infection control concerns by staff.
A resident with severe cognitive impairment was found with unsecured Mucinex tablets on her bedside table, which were brought by a family member without staff knowledge. The facility's ADON and DON confirmed that the medication should not have been in the room without a physician's order and assessment for self-administration, which were not present. Staff expressed concerns about potential overmedication due to unauthorized access.
A facility failed to maintain proper infection control when a CNA did not perform hand hygiene between glove changes during incontinence care for a resident with severe cognitive impairment. This action was against the facility's policy and could lead to cross-contamination. Staff interviews confirmed the importance of hand hygiene in preventing infections.
The facility failed to properly store and manage medications, with expired and discontinued drugs found in medication carts and refrigerators. Narcotic medications belonging to discharged residents were not documented or disposed of correctly, raising concerns about potential theft and medication errors. Staff interviews revealed non-compliance with facility policies on medication disposal and inventory management.
The facility failed to secure medication carts, leaving them unlocked and unattended, which could lead to unauthorized access by residents. The 3rd Floor Treatment Cart, 340 Hall Nurses Medication Cart, and 200 Hall Nurse Medication Cart were all found unlocked during a survey. Staff interviews revealed a lack of adherence to the facility's policy on securing medication carts, despite awareness of the requirement.
Failure to Notify Resident Representative Prior to Room Change
Penalty
Summary
The facility failed to provide required written notice, including the reason for a room change, to a resident and the resident’s Resident Representative (RR) before moving the resident from one room and floor to another. The resident, a male with diagnoses of depression, anxiety, and dementia but assessed as cognitively intact on a recent Quarterly MDS, was not his own Responsible Party. The room change notification form was signed by the resident, not the RR, and indicated he was being moved from the third floor to a Medicaid room on the fourth floor. Admission documents showed the RR had previously signed as the party consenting to treatment and held medical power of attorney for the resident’s care decisions. The RR reported she was not informed by the facility of the room change and only learned of it when the resident called her, and she stated she should have been notified of any changes involving the resident. The resident stated staff “shoved” a form in his face telling him he was going to be moved to the fourth floor, that he felt coerced into signing because it was presented as if he had no choice, and that he was unsure why he was being moved. In interviews, the Administrator stated she had been trained that if a resident was of sound mind, staff could inform the resident and the resident could inform the RR, and that the RR would only be notified if the resident was not coherent. The Administrator and Chief Nursing Operator (CNO) stated the resident had the right to make decisions regarding his care, and the Administrator acknowledged that staff notified the resident of the room change and relied on him to notify the RR. The CNO stated they would change the RR designation to the resident to avoid contacting the current RR for care decisions, despite the facility’s policy stating that the facility treats the decisions of the resident representative as the decisions of the resident to the extent delegated or required by law.
Failure to Notify Resident Representative of New Narcotic Pain Medication Order
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to notify a resident’s designated Resident Representative (RR) of a significant change in treatment. A male resident with dementia and depression, admitted in mid-2025 and assessed as having intact cognition on a quarterly MDS, had an order for Tramadol HCl 50 mg by mouth every 8 hours as needed for pain, prescribed in late 2025. The resident’s admission forms, signed earlier in 2025, showed that the RR had consented to the resident receiving treatment at the facility. However, record review and interviews revealed that the RR was not notified when Tramadol, a narcotic pain medication, was prescribed. The RR reported she was unaware the resident was receiving Tramadol and believed she should have been informed of the physician’s orders, particularly because the resident was a recovering alcoholic. During interviews, the RR stated she had spoken with the Administrator, who told her the facility did not have to contact the RR because the resident was of sound mind. The Administrator and Chief Nursing Operator confirmed they believed that, since the resident was coherent and able to make his own decisions, the RR did not need to be notified of the new medication order and that the RR would only be contacted if the resident was not coherent. The DON and ADON stated they were unsure whether consent from the RR was required when a resident was of sound mind, but indicated they generally tried to keep the RR informed because she was frequently in communication with nursing staff. Review of the facility’s Resident Representative policy defined the RR as an individual chosen by the resident to act on the resident’s behalf in decision-making and to receive notifications, but the RR was not notified of the Tramadol order as required.
Failure to Provide Required ADL Hygiene and Grooming Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance, including grooming and hygiene, to dependent residents. One male resident with hemiplegia affecting the left dominant side and a contracture of the left hand was totally dependent on staff for ADLs per his MDS and care plan. He filed a grievance on 12/17/25 about his fingernails not being trimmed. Photographs dated 01/05/26 provided by his responsible representative showed fingernails on both hands at least a half-inch long with thick black substance under some nails. The resident reported he had been requesting nail trimming for weeks from CNAs, a male nurse, and another staff member checking on residents, and that his long nails were digging into the palm of his contracted left hand. His responsible representative stated she had also been attempting for weeks to get his nails trimmed and had been assured by nursing staff and the Administrator that it would be done, but the nails were not trimmed until early January. A female resident with hemiplegia affecting the left dominant side, physical debility, severe cognitive impairment, and total dependence for ADLs was care planned as being at risk for skin breakdown and totally dependent on staff for ADL care. Review of her clinical record on 01/14/26 initially showed only one shower form dated 10/17/25 uploaded in the system. After this was brought to the attention of the ADON and DON, the facility produced additional shower/bed bath forms for December 2025 and January 2026, documenting bed baths on 12/05/25, 12/11/25, 12/16/25 (refused due to cold water), 12/20/25, 01/02/26, and 01/10/26. The resident stated she liked getting bed baths but had not been receiving them consistently, reporting that she had only received one bed bath in the prior week, needed her hair washed, and had not refused any bed baths. Staff interviews confirmed expectations and responsibilities related to ADL care that were not met. The LVN charge nurse for the hall stated she was unaware of the male resident’s untrimmed nails and indicated CNAs on the 2 PM–10 PM shift should check and trim nails during showers. She also stated that evening CNAs were responsible for the female resident’s showers and bed baths, that the resident was scheduled for showers three times weekly, and that it was her and the ADON’s responsibility to ensure residents received showers or bed baths. The ADON stated charge nurses were responsible for ensuring showers/bed baths and nail care were completed, that CNAs must complete showers/bed baths as scheduled, and that shower forms must be signed by nurses and uploaded to the record. He acknowledged being informed by the surveyor that only one shower sheet was uploaded for the female resident and said he would research the missing forms. The DON stated CNAs complete shower sheets, nurses sign them, and they are then scanned into the record, and that ADONs should be checking to ensure residents receive showers or bed baths. The facility’s ADL policy stated that appropriate care and services will be provided for residents unable to carry out ADLs independently, including assistance with hygiene such as bathing, dressing, grooming, and oral care.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents had access to their call light systems, which are necessary for requesting staff assistance, as required by their care plans and facility policy. During observations and interviews, it was found that three residents with severe cognitive impairment and significant physical limitations did not have their call lights within reach. In each case, the call light was observed on the floor, out of the resident's reach, and the residents were unaware of the location of their call lights when asked. Record reviews indicated that these residents were dependent on staff for all or substantial assistance with activities of daily living and were identified as fall risks. Their care plans specifically included interventions to ensure call lights were accessible. Despite this, staff interviews revealed that although there were procedures in place to check and clip call lights within reach during rounds, these procedures were not consistently followed, resulting in the call lights being inaccessible at the time of surveyor observation. Multiple staff members, including CNAs, LVNs, the DON, ADON, and the Administrator, acknowledged awareness of the importance of keeping call lights within reach and described ongoing efforts to remind staff of this requirement. However, the deficiency persisted, as evidenced by direct observation and staff admissions that call lights were not always secured or checked as required. The facility's own policy emphasized the necessity of ensuring call lights are accessible to residents when in bed, but this standard was not met for the three residents reviewed.
Failure to Secure Resident Medical Information and Maintain Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of personal and medical records for eight residents. On the specified date, an untitled piece of paper containing the blood pressure, pulse rate, and oxygen saturation of these residents was left on top of a nurse's cart parked in the hallway. Additionally, a laptop on the same cart was left open and unattended, displaying the residents' pictures and indicating their skilled nursing status. The cart was positioned facing the hallway, where several staff members were observed walking back and forth, making the information accessible to unauthorized individuals. Interviews with staff confirmed that the nurse had left the cart to assist a resident and did not secure the paper or close the laptop before leaving. The nurse acknowledged that best practice would have been to secure all resident information before leaving the cart unattended. The Director of Nursing (DON), Administrator, and Assistant Director of Nursing (ADON) all stated that personal and medical information should be protected and not visible to unauthorized individuals, including staff not involved in the residents' care, visitors, and vendors. They confirmed that the information left exposed included vital signs, names, pictures, and care levels, all of which are considered protected health information. A review of the facility's policy on confidentiality and personal privacy indicated that the facility is required to safeguard the personal privacy and confidentiality of all resident personal and medical records. The observed actions were inconsistent with this policy, as sensitive information was left exposed and unattended in a public area, accessible to individuals without authorization.
Failure to Secure Medications and Biologicals
Penalty
Summary
Surveyors identified that the facility failed to store drugs and biologicals in accordance with state and federal regulations, resulting in multiple instances where medications were left unsecured and accessible to residents. Specifically, tubes of zinc oxide, a medicated barrier cream, were found left in the rooms of three different residents. In each case, the zinc oxide was observed on top of dressers or side tables, within easy reach of the residents. For one resident, who was cognitively intact and always incontinent, the zinc oxide was left on his dresser and used by staff after each episode of incontinence. There was no assessment for self-administration or documentation that the resident was competent to manage his own medications. For two other residents, both with severe cognitive impairment and incontinence, tubes of zinc oxide and a container of wound cleanser were also found in their rooms, with no clear explanation as to why these items were not secured in the treatment cart as required. Additionally, surveyors observed a vial of solution for a breathing treatment left unattended on top of a nurse's cart in a hallway. The cart was facing the hallway and was not attended by staff, while residents and staff passed by. The nurse responsible for the cart acknowledged that she had left the medication unattended when called away, and recognized the risk that residents could access the medication. Facility staff, including CNAs, wound care nurses, the DON, and the ADON, all confirmed during interviews that medications, including medicated ointments and wound cleansers, should not be left in resident rooms or unattended on carts, as this could lead to improper use or ingestion by residents. Record reviews confirmed that facility policy required all medications and biologicals to be stored in locked compartments and not left unattended or accessible to residents. The policies also specified that only authorized personnel should have access to medications and that medications should not be kept on top of carts. Despite these policies, the observed actions and inactions of staff led to multiple instances where medications were not properly secured, resulting in a deficiency related to medication storage and access.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff not following established protocols. In the first incident, a certified nursing assistant (CNA) provided incontinent care to a female resident with kidney failure and incontinence. During the care, the CNA changed gloves multiple times without sanitizing her hands between glove changes, despite being aware that hand hygiene was required to prevent cross-contamination. The resident's care plan specifically required pericare after each episode of incontinence, and the facility's policy mandated hand hygiene after removing gloves. In the second incident, a licensed vocational nurse (LVN) disconnected an intravenous (IV) line from a male resident who had an infection related to a right knee prosthesis and was receiving antibiotics via a PICC line. The resident was under Enhanced Barrier Precautions (EBP), which required staff to wear both gloves and a gown during high-contact care activities, including device care. Despite signage outside the resident's room and physician orders indicating the need for a gown, the LVN only wore gloves and did not don a gown while disconnecting the IV. Interviews with staff, including the CNA, LVN, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator, confirmed awareness of the required infection control procedures. Staff acknowledged the lapses and recognized the importance of hand hygiene and gown use in preventing the spread of infection, as outlined in the facility's policies. However, these protocols were not followed during the observed care activities, resulting in deficiencies in infection prevention and control.
Failure to Maintain Resident Dignity by Not Covering Gall Bladder Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of acute cholecystitis and a gall bladder tube (C-tube) was observed with her gall bladder drainage bag uncovered and in public view. The resident's physician order specifically required that the bag be covered with a pillowcase for privacy and dignity. During the survey, the Assistant Director of Nursing (ADON) and the surveyor observed the uncovered bag on the resident's bed. The ADON acknowledged that the bag should have been covered for dignity reasons and was unsure why it was not. Further interviews with nursing staff, including an LVN and another ADON, confirmed that the bag was not covered during their rounds and that it should have been concealed for privacy, infection control, and dignity. The Director of Nursing (DON) also confirmed that the resident should have had a privacy bag or pillowcase to cover the gall bladder bag, as required by facility policy and physician orders. The facility's policy on dignity emphasized the importance of caring for residents in a manner that promotes their well-being and self-esteem.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the nurse call system was accessible for three residents who required varying levels of assistance with activities of daily living (ADLs) and had significant medical conditions. Observations revealed that the call lights for these residents were found on the floor and out of reach while the residents were in bed. One resident, with severe cognitive impairment and muscle weakness, had her call light on the floor near the bedside table. Another resident, also with severe cognitive impairment and total dependence for ADLs, was unable to locate his call light and expressed a need for assistance to urinate. The third resident, who was a fall risk and required substantial assistance, had her call light under the nightstand and out of reach. Record reviews indicated that care plans for at least two of these residents specifically required that call lights be kept within reach and that residents be encouraged to use them. Staff interviews confirmed that call lights should be accessible to residents and acknowledged that the devices may have been knocked down during movement in bed. The facility's policy also required that call lights be accessible to residents when in bed, but this was not followed at the time of the observations.
Failure to Obtain Physician Orders for Bolster Mattresses Used as Physical Restraints
Penalty
Summary
The facility failed to ensure that two residents were free from the use of physical restraints not required to treat medical symptoms, specifically regarding the use of bolster mattresses. For one resident with muscle weakness and unsteadiness, the care plan identified her as a fall risk and included the use of a bolster mattress as an intervention. However, there was no physician order for the device, and the resident was observed lying on the bolster mattress. Facility staff confirmed that a physician order was required but not present in the records. Similarly, another resident with repeated falls and muscle weakness was observed using a bolster mattress, but there was no care plan or physician order for the device. Staff interviews confirmed the absence of required physician orders for both residents. The facility's policy required an interdisciplinary assessment and physician orders for such devices, but these steps were not followed, resulting in the deficiency.
Failure to Properly Store Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required nebulizer treatments for acute and chronic respiratory failure. On the date of observation, the resident's nebulizer mask was found unbagged in her nightstand after use, contrary to professional standards of practice and the facility's own policy, which requires the mask to be bagged when not in use to prevent infection. The LVN responsible for the resident's care acknowledged that she had overlooked bagging the mask after the morning treatment. The resident in question was an elderly female with a diagnosis of acute respiratory failure, requiring extensive assistance with activities of daily living and regular nebulizer treatments as ordered by her physician. The deficiency was identified through observations, interviews with staff, and review of the resident's medical records and care plan, all of which confirmed that the required infection control practice of bagging the nebulizer mask was not followed.
Failure to Provide Accessible Call Light System for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and bilateral hand contractures had access to a call light system that accommodated her physical limitations. On observation, the resident was found lying in bed with her call light not within reach, as it was hanging on the back wall behind the bed. The resident's hands appeared contracted, and she was unable to communicate coherently. Staff interviews revealed uncertainty about whether the resident could use the standard call light button or a touch pad, and it was confirmed that no assessment had been completed upon admission to determine the resident's ability to use the call light system. The Director of Nursing (DON) and other staff acknowledged that the resident required total care and was a full code, but admitted that the admitting nurse had not assessed the resident's ability to use the call light or touch pad. The facility's policy required that residents with disabilities preventing use of the standard call system be provided with an alternative means of communication, documented in the care plan. However, this was not done for the resident in question, resulting in the resident not having a call light system accessible or suitable for her needs at the time of the survey.
Failure to Obtain Physician Orders for Use of Physical Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. A female resident with muscle weakness, lack of coordination, and severe cognitive impairment was observed in bed with bolster pads attached to all sides of her mattress, which prevented her from freely exiting the bed. Review of her care plan and physician orders revealed no documentation or orders for the use of these bolster pads as a restraint or safety device. The resident's care plan did not include the use of bolster pads as an intervention, and there were no physician orders authorizing their use. Interviews with the DON, ADON, and Administrator confirmed that the resident had arrived at the facility with the bolster pads, which had been provided by hospice, but staff were unaware of the need for physician orders for this equipment. The facility's policy defined physical restraints as any device that restricts freedom of movement and cannot be easily removed by the resident. The lack of physician orders and care plan documentation for the bolster pads constituted a failure to ensure the resident's environment was free from unauthorized restraints.
Failure to Protect Resident Medical Record Confidentiality
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for five residents, as required by policy. On the specified date, a piece of paper containing the names, vital signs, and blood sugar readings of five residents was left exposed and unattended on top of a nurse's cart in a hallway. The cart was unattended and located in an area with frequent staff traffic, making the information visible to unauthorized individuals. The residents involved had various medical conditions, including diabetes mellitus and hypertension, and their medical information was documented on the exposed paper. The information included sensitive data such as blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, and blood sugar levels. The exposure occurred when an LVN left the cart to administer treatment to a resident, leaving the paper unsecured. Facility staff, including the ADON, Administrator, and DON, acknowledged that the residents' information was confidential and should not have been left exposed. They confirmed that the expectation was for all staff to protect residents' personal and medical information at all times, and that leaving such information unattended constituted a violation of privacy and confidentiality policies.
Failure to Properly Store Nasal Cannulas for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that nasal cannulas used for oxygen therapy were properly stored when not in use for three residents. Observations revealed that one resident's nasal cannula was left spread out on top of the bed, another resident's nasal cannula was found on the floor, and a third resident's nasal cannula was placed on a side table with the prongs touching the surface. In each case, the nasal cannulas were not bagged as required by facility policy and professional standards of practice. The residents involved had significant medical needs requiring oxygen therapy, including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and conditions such as intracranial hemorrhage and seizures. Documentation confirmed that these residents had physician orders for continuous oxygen therapy and care plans reflecting their respiratory needs. Despite these documented requirements, staff did not consistently follow procedures to prevent contamination of respiratory equipment. Interviews with staff and residents confirmed that the nasal cannulas were not stored in plastic bags when not in use, and staff acknowledged that this practice was necessary to prevent infection. The facility's own policy specified that oxygen cannulas and tubing should be kept in a plastic bag when not in use, but this was not followed, resulting in a failure to meet professional standards and the residents' care plans.
Unsecured Wound Care Cart with Medications and Biologicals Left Unattended
Penalty
Summary
A wound care cart was observed parked in a hallway near the rehabilitation department with its lock protruding, indicating it was not secured. The cart and its drawers, which contained wound care supplies such as normal saline, triple antibiotics, and wound cleanser solutions, were easily accessible and could be opened by anyone passing by, including residents and staff. The cart was left unattended and unlocked in an area with frequent resident and staff traffic, and the contents could be easily taken. Interviews with the DON, ADON, and Administrator confirmed that the cart should have been locked when not in use and that the expectation was for staff to secure all medication and wound care carts when unattended. The facility's policy also required all medications and biologicals to be stored in locked compartments when not in use. The DON was unaware of how long the cart had been left unlocked and believed it may have been last used by night nurses.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, leading to several deficiencies. Observations revealed that kitchen staff did not wear appropriate beard and hair coverings, with one staff member having a beard without a covering and others with ponytails protruding from their caps. Additionally, food storage practices were inadequate, with items in the refrigerator not properly sealed, and expired food not discarded. The ice machine and its scoop holder were not maintained properly, exposing them to airborne contaminants. Furthermore, a large trash can in the kitchen was left uncovered, and food storage bins in the dry storage area were found to be dirty. The facility's policies on food receiving, storage, and sanitation were not followed, as evidenced by the presence of dirt and rust in the ice machine, uncovered food items, and improper labeling and dating of refrigerated foods. The Dietary Manager acknowledged the issues but had not yet addressed them with the Executive Director. The Executive Director was aware of the potential for food contamination and illness among residents due to these lapses but had not yet taken corrective action. The facility's failure to comply with local, state, and federal standards for food safety and sanitation was evident in the observed deficiencies.
Failure to Ensure Proper Wound Care Documentation and Treatment
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, based on the comprehensive assessment and professional standards of practice. A resident, who was cognitively intact and had a history of rheumatoid arthritis and age-related physical debility, was observed with a wound bandage on her right elbow that was dated 10 days prior to the observation. The resident's care plan indicated a high risk for skin-related injury, and the wound care was to be provided per the physician's orders. However, there was no physician order for a dressing on the resident's right elbow, and the wound care nurse, upon returning from leave, discovered the outdated dressing and no corresponding order in the resident's chart. The wound care nurse, upon discovering the issue, removed the old dressing and noted dried blood and scant serosanguinous drainage. The nurse then contacted the resident's doctor to report the skin tear and received an order for wound care. The facility had been using agency nurses during the wound care nurse's absence, and it was noted that the lack of a documented order could lead to nurses being unaware of the need to change the dressing, potentially causing infection. The facility's policy on wound care emphasized the importance of following provider's orders to promote healing, which was not adhered to in this instance.
Infection Control Concerns in Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, leading to potential infection control concerns. Resident #10, a male with severe cognitive impairment and diagnosed with sleep apnea, had his CPAP hose placed on the floor, disconnected from the mask. This placement was identified as a contamination risk by an LVN, as the floor is not a sanitary area for medical equipment. The resident's care plan required the use of a CPAP machine, and the improper storage of the hose was inconsistent with professional standards of practice. Similarly, Resident #80, a female with intact cognitive response and requiring continuous oxygen therapy, had her nasal cannula hanging unbagged on her headboard while she was not in the room. The tubing was also observed balled up on the floor, which was noted as a contamination risk by an LVN. The facility's policy required that oxygen cannulas and tubing be stored in a plastic bag when not in use to prevent infection. Both instances were acknowledged by the DON and the Executive Director as infection control concerns.
Unsecured Medication Found in Resident's Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and allowed unauthorized access to medication for one resident. Specifically, a box of Mucinex tablets was found unattended and unsecured on the bedside table of a resident with severe cognitive impairment. The resident, who had been diagnosed with Covid-19 and acute respiratory failure, stated that a family member had brought the medication to her a long time ago, but she had not taken any of it. The facility's Assistant Director of Nursing (ADON) confirmed that the medication should not have been in the resident's room without an assessment and physician's order for self-administration, which was not present in the resident's chart. Interviews with facility staff, including the ADON, a Licensed Vocational Nurse (LVN), and the Director of Nursing (DON), revealed that the medication was not authorized for self-administration and should have been removed from the resident's room. The staff expressed concerns that the resident could have taken the medication without supervision, potentially leading to overmedication. The DON acknowledged that family members sometimes brought items to residents without staff knowledge and confirmed that the facility's policy required medications found at the bedside without authorization to be turned over to the nurse in charge.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of CNA B during incontinence care for Resident #32. Resident #32, a female with severe cognitive impairment and incontinence, was observed receiving care where CNA B did not perform hand hygiene between glove changes. Specifically, CNA B changed gloves multiple times without using hand sanitizer or washing hands, which is contrary to the facility's policy and standard infection control practices. The deficiency was highlighted during an observation where CNA B provided incontinence care without adhering to proper hand hygiene protocols, potentially risking cross-contamination. Interviews with staff, including LVN A, the ADON, and the DON, confirmed the importance of hand hygiene in preventing the spread of infections. The facility's policy requires hand sanitization or washing between glove changes, which was not followed in this instance, leading to the identified deficiency.
Improper Storage and Management of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as observed in two medication carts and two medication refrigerators. On the 2nd floor, the medication refrigerator contained narcotic medications belonging to discharged residents without the necessary narcotic sheet records. Similarly, the 3rd floor medication cart and refrigerator contained expired and discontinued medications that were not removed after residents were discharged. These lapses in medication management could lead to residents being exposed to medications not intended for them or receiving expired medications with reduced potency. The report highlights specific instances where medications were not managed according to professional principles. For example, insulin pens and bottles of Lorazepam were found in the medication room and carts, belonging to residents who had been discharged. The facility's staff, including LVNs and RNs, acknowledged that medications of discharged residents should be handed over to the ADON for disposal, but this process was not followed. Additionally, there were no narcotic sheets for certain medications, raising concerns about potential theft or mismanagement. Interviews with staff revealed a lack of adherence to the facility's policies regarding medication disposal and inventory management. The DON and ADON confirmed that expired medications should be disposed of in a locked trash bin, and narcotic medications should be accounted for to prevent theft. However, the absence of proper documentation and disposal practices led to the presence of expired and discontinued medications in the facility, posing a risk of medication errors and adverse reactions among residents.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. Specifically, the 3rd Floor Treatment Cart was observed unlocked and unattended, containing medications such as Mupirocin and Bacitracin ointments. Additionally, the 340 Hall Nurses Medication Cart was found unlocked with no staff present, and the 200 Hall Nurse Medication Cart was left unlocked in the dining room of the secured unit. These lapses in securing medication carts were observed during a survey, with staff and residents passing by the unsecured carts. Interviews with staff revealed a lack of adherence to the facility's policy on securing medication carts. RN A and MA B, who shared responsibility for the 340 Hall Nurses Medication Cart, both acknowledged the importance of locking the carts but failed to do so. LVN C admitted to being distracted and forgetting to lock the 200 Hall Nurse Medication Cart. The ADON and DON both stated that staff were aware of the policy requiring carts to be locked when not in use, and the Administrator emphasized the expectation for staff to secure medication carts to prevent unauthorized access by 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.
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