Simpson Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 3922 Simpson Street, Dallas, Texas 75246
- CMS Provider Number
- 676453
- Inspections on file
- 50
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Simpson Place during CMS and state inspections, most recent first.
A resident with intact cognition and multiple psychiatric and medical diagnoses required supervision or touching assistance with personal hygiene ADLs per the MDS, but surveyors found the comprehensive care plan lacked any measurable objectives, goals, interventions, or timeframes for ADLs. The DON reported that every resident should have a care plan reflecting preferences and routines and acknowledged that missing ADL information reduced staff communication and knowledge of preferences. The DON and Administrator both stated that the MDS Coordinator was responsible for updating care plans, charge nurses for triggering acute plans, and that the facility did not have an MDS Coordinator, resulting in the resident’s ADL needs not being incorporated into the care plan despite facility policy.
A cognitively intact male resident with multiple psychiatric and medical diagnoses, who required supervision or touching assistance for personal hygiene, was observed with an overgrown mustache and a long chin beard despite his admission photo showing a trimmed mustache and clean-shaven face. He reported receiving regular showers but stated he had been asking for weeks to have his mustache trimmed and beard shaved, and was told by staff he needed to schedule and pay for beauty salon services, which he could not afford. The CNA assigned to him had showered him but did not shave him, did not ask about his grooming preferences, and did not consult the charge nurse, despite stating CNAs are responsible for shaving on shower days if requested. The RN, DON, and Administrator each stated that CNAs are responsible for grooming, including shaving, and that nursing leadership is responsible for ensuring care is provided, but none were aware of the resident’s repeated requests. The resident’s care plan lacked ADL goals and interventions, and the facility’s policy required provision of hair care and shaving per standard practice guidelines.
Surveyors found that a resident with complex medical conditions, including COPD, chronic respiratory failure on O2, diabetes, CKD, and prior episodes of hypernatremia and hypoxia, experienced multiple hospitalizations and returned with changes in diet (thickened liquids), respiratory treatments, and IV therapy, but the facility did not complete a required Significant Change in Status Assessment (SCSA) MDS. Review of the admission and quarterly MDSs showed missing or inaccurate coding, including an empty BIMS summary score on one assessment and Section O indicating no special treatments despite documented use of oxygen and IV fluids. Interdisciplinary notes and MD orders confirmed ongoing O2 use, IV fluids, and aspiration precautions, while interviews with the CRN, DON, and ADM confirmed that no significant change MDS was present and that it was the responsibility of leadership and MDS staff to ensure timely and accurate assessments.
A resident with metabolic encephalopathy, DM, hypernatremia, and acute/chronic respiratory failure experienced multiple hospitalizations and returned with clinical changes including thickened liquids, respiratory treatments, and IV/enteral feeding, but these changes were not accurately captured on the MDS. One MDS had an undocumented assessment type and an empty BIMS summary score, and a subsequent quarterly MDS documented severe cognitive impairment and SOB but failed to include the need for thickened liquids in Section K and showed no special treatments such as oxygen or IV in Section O. The care plan and staff interviews confirmed oxygen therapy and diet changes, while leadership acknowledged that MDS assessments were not timely or accurate and that no change in condition MDS could be located, contrary to facility policy requiring comprehensive, accurate, and timely MDS completion.
Staff failed to follow infection control protocols during care of two residents, including not wearing required PPE such as gowns during high-contact procedures for a resident on Enhanced Barrier Precautions, not performing hand hygiene between glove changes, and placing soiled linen on the floor instead of in a designated bag. These actions were contrary to facility policies and were acknowledged by staff and leadership as lapses that could lead to cross-contamination.
A resident with multiple chronic conditions and significant ADL assistance needs did not have a comprehensive care plan addressing ADLs, including measurable objectives and timeframes, despite these needs being identified in assessments. Facility staff confirmed that the omission reduced communication and awareness of the resident's preferences and required care.
A resident with frequent incontinence and multiple chronic conditions did not receive timely incontinence care, as her brief was not changed throughout the morning. The CNA responsible had not provided care since the start of the shift, citing a heavy workload. Staff interviews and facility policy confirmed that care should be provided every two hours or as needed, but this expectation was not met.
A resident with an indwelling urinary catheter did not receive proper catheter care during a transfer, as a CNA placed the drainage bag above bladder level, resulting in observed urine backflow. Staff interviews confirmed knowledge of correct procedures, but the facility's policy did not address this issue.
The facility's kitchen failed to label opened food items, such as liquid eggs, with use-by dates, as required by professional standards and the facility's policy. This oversight was confirmed through observations and staff interviews, highlighting a risk of food-borne illness to residents. The facility's policy mandates that all foods be covered, labeled, and dated, in accordance with FDA guidelines.
The facility failed to complete and transmit discharge MDS assessments for two residents within the required 14-day period. A change in the electronic health record system contributed to the oversight, as staff were unable to access previous assessments. The MDS Nurse and Regional MDS RN acknowledged the lapse, which resulted in incomplete records for the residents.
A facility failed to include dialysis in a resident's care plan, despite the resident being admitted as a dialysis patient. The resident, who was cognitively intact, had multiple diagnoses including peripheral vascular disease and hypotension of hemodialysis. The omission was acknowledged by the DON and MDS Coordinator, who noted the importance of reflecting physician orders in the care plan.
The facility failed to provide necessary nail care for two residents, both of whom were unable to maintain personal hygiene independently. One resident, dependent on staff for personal hygiene, had dirty and jagged nails, while another resident, requiring moderate assistance, had long, discolored nails. Staff interviews revealed that nail care was the responsibility of CNAs and nurses, to be performed on shower days and as needed. Despite this, the residents did not receive adequate nail care, potentially increasing their risk of infections.
A resident with an indwelling urinary catheter was at risk for infection when a CNA placed the catheter drainage bag above bladder level during wound care, causing urine backflow. Despite training, the CNA failed to follow the care plan, which required the bag to be kept below the bladder. The facility's policy did not address this specific concern.
A facility failed to label an insulin pen with an open date, as observed on a nurses' cart. An LVN administered insulin without checking for an open date, acknowledging the importance of labeling for effectiveness. The DON confirmed the requirement for dating insulin pens and vials, with monthly checks by a pharmacy consultant and random checks by the DON and ADON.
The facility failed to maintain an effective pest control program, resulting in bed bug sightings on the 600 floor. Two residents reported bed bugs in their rooms, and the facility did not follow its bed bug policy, which required checking all rooms on the affected floor and training staff on prevention. Some staff were unaware of the issue, and there was a lack of documentation and communication regarding the sightings and treatments. The pest control treatments were not effective, contributing to the ongoing bed bug issue.
A resident with moderate cognitive impairment and complex medical conditions was verbally and mentally abused by a CNA. The incident was captured on video, showing the CNA removing the call light from the resident's hand, refusing to change her when wet, and speaking disrespectfully. The facility's investigation confirmed the inappropriate behavior, violating the resident's right to be free from abuse.
Two residents were found using wheelchairs with damaged armrests, exposing them to potential injury. Staff, including the ADON and Maintenance Director, were unaware of the issues, and there was no documentation in the maintenance log. The facility lacked a structured process for reporting and repairing equipment, placing residents at risk.
The facility failed to ensure proper hair restraint use by dietary staff, as observed with a dietary aide who did not fully cover her hair while preparing meals. Despite having sufficient hairnets available, the aide's hair was not completely restrained, posing a risk of food contamination. Interviews revealed that staff were aware of the importance of hairnets, but compliance was inconsistent.
A facility failed to implement a comprehensive care plan for a resident, missing a weekly skin assessment required by the care plan. The resident, with a history of dementia and hemiplegia, had a stage 3 pressure wound. Interviews revealed that the ADON and DON were responsible for the assessments but missed the audit, risking inadequate care. The facility's policy mandated weekly skin checks to prevent pressure ulcers.
A resident with multiple health conditions experienced a breach in infection control when an RN removed gloves and used hand sanitizer over an open wound. Despite being trained, the RN admitted to being nervous and unaware of the risk of contamination. Facility staff confirmed the RN's understanding of proper wound care protocols.
Failure to Develop Comprehensive ADL Care Plan for a Resident
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for one resident. Record review showed this male resident, with diagnoses including UTI, anxiety disorder, bipolar disorder, schizophrenia, and depression, had an MDS assessment indicating intact cognition (BIMS score of 15) and a need for supervision or touching assistance with personal hygiene tasks such as combing hair, shaving, and washing/drying face and hands. However, review of the resident’s care plan, last reviewed on 02/11/26, revealed no plan of care addressing ADLs with measurable objectives, goals, interventions, and timeframes, despite the facility’s written policy requiring a comprehensive person-centered care plan to meet medical, nursing, mental, and psychosocial needs. During interviews, the DON stated that every resident should have a care plan reflecting their likes, dislikes, everyday routine, and anything that affected them, and acknowledged that the absence of ADLs in the care plan diminished staff communication and knowledge of resident preferences. The DON explained that the MDS Coordinator was responsible for updating residents’ care plans, but the facility did not have an MDS Coordinator nurse and instead used a corporate person for MDS assessments, while the DON handled acute and new resident care plans. The Administrator similarly stated that the care plan told a story about the resident’s care and preferences and confirmed that without ADLs listed, staff would not know what residents liked. The Administrator indicated that charge nurses were responsible for triggering acute care plans and the MDS Coordinator for updating care plans, but again noted the absence of an MDS Coordinator.
Failure to Provide Requested Shaving and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who required assistance with activities of daily living (ADLs) received necessary grooming and personal hygiene services, specifically shaving. The resident was an adult male with diagnoses including urinary tract infection, anxiety disorder, bipolar disorder, schizophrenia, and depression. His MDS showed intact cognition with a BIMS score of 15 and indicated he required supervision or touching assistance with personal hygiene tasks such as combing hair and shaving. His face sheet photo showed him with a trimmed mustache and clean-shaven face at admission. During observation, he was seen clean and groomed but with a full mustache growing over his lip and a chin beard approximately two inches long, which differed from his admission appearance. The resident reported he received showers three times a week but wanted his mustache trimmed and beard clean-shaven, and stated he had been asking to be shaved for weeks. He said staff told him he needed to make an appointment with the facility’s beauty salon, which he could not afford, and he confirmed he was not admitted with a beard. There was no care plan addressing ADLs with measurable objectives, goals, interventions, and timeframes. The CNA assigned to him on the day of observation stated she had showered him but had not shaved him or asked about his grooming preferences, and she had not consulted the charge nurse. She stated CNAs were responsible for shaving residents on shower days if requested. The RN, DON, and Administrator each stated that CNAs were responsible for grooming, including shaving, on shower days and that charge nurses, the DON, and the Administrator were responsible for ensuring residents received appropriate care. None of them were aware the resident had been requesting shaving. The facility’s policy stated that hair care, combing, and shaving would be provided in accordance with standard practice guidelines.
Failure to Complete Significant Change MDS After Multiple Hospitalizations and Treatment Changes
Penalty
Summary
The deficiency involves the facility’s failure to complete a comprehensive, accurate Significant Change in Status Assessment (SCSA) MDS within 14 days after a resident experienced significant changes in condition and multiple hospitalizations. The resident, an older male admitted with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated with the type left blank and key sections either incomplete or inaccurately coded. Section C (Cognitive Patterns) showed an empty BIMS summary score and staff assessment indicating memory problems and inattention. Section J documented shortness of breath with exertion, at rest, and when lying flat, and Section K noted parenteral/IV feeding while not a resident. Section O (Special Treatments) was left empty and did not address the resident’s oxygen and IV use. A subsequent quarterly MDS documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath in multiple positions and parenteral/IV feeding under Section K. However, Section O again indicated that the resident did not require any special treatments such as IV or oxygen, despite medical records showing orders and use of these treatments. The record showed MD orders for IV fluids, PRN albuterol nebulizer treatments, and PRN peripheral IV restarts for infiltration or extravasation. MD progress notes documented initiation of IV normal saline, completion of a BIMS with a score of 15/15 at one point, and the presence of a peripheral IV line. Interdisciplinary notes described a history of chronic respiratory failure on 2L nasal cannula O2, COPD, CKD, mood disorder, prior admissions for atypical chest pain, leukocytosis, hypernatremia, hypoxia with AMS, pulmonary embolism, aspiration pneumonia, GI bleed, AKI, and the need for thickened liquids with aspiration precautions. The resident experienced multiple hospitalizations for atypical chest pain, hypoxia, altered mental status, leukocytosis, and later for severe hypernatremia, with documented changes in diet (thickened liquids), respiratory treatments, and IV therapy upon return to the facility. The facility’s own change of condition policy defined acute changes of condition and circumstances requiring communication and evaluation, including transfer to another healthcare community and unexpected deterioration in condition or status. Despite these significant clinical events and changes in treatment approaches, there was no significant change in condition MDS assessment in the resident’s file. Interviews with the CRN and DON confirmed that the resident had several hospitalizations and returned with clinical changes to diet, respiratory treatments, and IV therapy, and that the MDS should accurately reflect current care status and needs. The DON and ADM acknowledged that it was the responsibility of the ADON, MDSC, and DON to ensure timely and accurate completion of MDS assessments, and that the facility had not completed a change in condition assessment for this resident. The care plan documented cognitive loss, dietician referral, prescribed diet, altered nutrition status related to weight loss, shortness of breath, risk of dehydration, oxygen therapy related to COPD, and extensive assistance needs with ADLs, but there remained no corresponding significant change MDS to capture the resident’s updated status following the hospitalizations and treatment changes. During surveyor interviews, the resident provided minimal information about recent hospitalization, oxygen treatments, and thickened water, responding only "whatever they said." The CRN initially stated that updated MDS assessments were in the EMR but was unable to produce a significant change MDS. The ADM reported that the facility had recently terminated the MDSC after observing a pattern of failing to complete timely and accurate assessments and confirmed that the DON was responsible for monitoring and ensuring that the MDS was updated. Overall, the survey findings showed that despite clear evidence of significant changes in the resident’s physical and clinical status, the facility did not complete the required significant change MDS assessment and did not accurately code existing MDSs to reflect oxygen and IV treatments and diet changes. The facility’s written policy on change of condition emphasized the importance of recognizing and managing acute changes of condition and defined an acute change as a sudden, clinically important deviation from baseline that, without intervention, may result in complications or death. The resident’s multiple hospitalizations for serious conditions, including hypernatremia, hypoxia, and aspiration pneumonia, along with changes in diet consistency, respiratory support, and IV therapy, met the criteria for significant change. Nonetheless, the record review and staff interviews confirmed that no significant change MDS was completed, and existing MDS assessments were incomplete or inaccurate in key sections, particularly Section O for special treatments. This failure to conduct and accurately complete a significant change assessment within the required timeframe formed the basis of the cited deficiency.
Inaccurate MDS Assessments for Diet and Respiratory Treatments After Change in Condition
Penalty
Summary
Surveyors identified a failure to ensure that a resident’s Minimum Data Set (MDS) assessments accurately reflected the resident’s current clinical status, specifically related to diet and respiratory treatments. Record review showed that the resident, an older male with diagnoses including metabolic encephalopathy, diabetes mellitus with hyperosmolality, hypernatremia, and acute and chronic respiratory failure with hypoxia, had an MDS dated 09/09/2025 with an undocumented assessment type and an empty BIMS summary score field. This MDS documented shortness of breath with exertion, at rest, and when lying flat, and noted parenteral/IV feeding while not a resident, but did not clearly capture subsequent clinical changes. The resident was hospitalized multiple times and returned with changes in diet approaches, including thickened liquids, and with respiratory treatments and IV for enteral feeding. The quarterly MDS completed later by an LVN/MDS nurse documented a BIMS score of 07, indicating severe cognitive impairment, and again noted shortness of breath with exertion, at rest, and when lying flat. In Section K, the quarterly MDS continued to list parenteral/IV feeding as a nutritional approach but did not address the resident’s need for thickened liquids. In Section O, the assessment indicated that the resident did not require any special treatments, such as IV or oxygen, despite other information indicating oxygen therapy and respiratory treatments. Section Z of this quarterly MDS was signed by an RN on 12/23/2025, certifying completion of the assessment. Additional documentation and interviews confirmed that the resident’s care needs had changed and were not reflected in a corresponding change in condition MDS. The care plan dated 01/14/2026 included problems and interventions such as cognitive loss, dietician referral, prescribed diet, altered nutritional status, shortness of breath, risk of dehydration, and oxygen therapy related to COPD, and noted that the resident recently received thin liquids and was progressing in speech. The CRN stated the resident had been hospitalized several times and returned with clinical changes including thickened liquids, respiratory treatments, and IV for enteral feeding, and acknowledged the need to check updated MDSs. The DON stated that MDS clinical assessments and plans should be updated to reflect the resident’s current status and that failing to complete or update MDS assessments placed the resident at risk of missing individualized clinical care, treatment, and tasks. The ADM reported that the facility had observed a pattern of failing to complete timely and accurate assessments and that the MDS coordinator had been terminated, and staff were unable to produce a change in condition MDS for this resident. The facility’s policy required comprehensive, accurate MDS assessments, coordinated and certified by an RN, and completed on admission, annually, quarterly, and within 14 days of a significant change, but this process was not followed for this resident’s change in condition.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple staff not adhering to required infection control practices during care of two residents. For one resident with a suprapubic catheter and wounds, who was under Enhanced Barrier Precautions (EBP) isolation, several staff members, including an LVN and three CNAs, provided care without wearing gowns as required for high-contact procedures. Observations showed that while gloves were used, gowns were not donned, and staff were unaware or forgot the necessity of this PPE despite the presence of a PPE supply cart outside the room. There was also no EBP isolation signage present. Interviews revealed that some staff did not know the purpose of the PPE cart or the need for gowns, and one staff member admitted to rushing and forgetting proper PPE due to time constraints. In another instance, during incontinent care for a different resident, a CNA failed to perform hand hygiene between glove changes, and an LVN placed dirty linen on the floor instead of in a designated plastic bag. The CNA acknowledged knowing the correct procedure but did not follow it due to nervousness, while the LVN stated that placing dirty linen on the floor was not an issue, despite facility policy requiring dirty linen to be bagged. The administrator and DON confirmed that staff were expected to perform hand hygiene before and after care, between glove changes, and to properly handle soiled linen, but these protocols were not followed during the observed care. Record reviews and staff interviews confirmed that the facility had policies in place for hand hygiene and EBP, requiring gowns and gloves for high-contact care and proper handling of soiled linen. However, the observed failures in PPE use, hand hygiene, and linen handling during resident care directly contradicted these policies and placed residents at risk for cross-contamination and infection, as acknowledged by staff and leadership during interviews.
Failure to Develop Comprehensive Care Plan for ADLs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for activities of daily living (ADLs) for a resident. Record review showed that the resident, a 90-year-old individual with multiple diagnoses including idiopathic peripheral autonomic neuropathy, depression, secondary hypertension, atrial fibrillation, and chronic diastolic congestive heart failure, required varying levels of assistance with ADLs such as toileting hygiene, bathing, dressing, eating, and oral hygiene. Despite these needs being identified in the most recent MDS assessment, the resident's care plan did not include a plan of care for ADLs, nor did it specify measurable goals, interventions, or timeframes related to these needs. Interviews with facility staff, including the Administrator, DON, and MDS Nurse, confirmed that the absence of ADLs in the care plan diminished staff communication and knowledge of the resident's preferences and routines. The staff acknowledged that the care plan should reflect the resident's functioning, preferences, and required assistance, and that the MDS Coordinator was responsible for updating the care plan. Review of the facility's care plan policy indicated that the interdisciplinary team is required to coordinate and review care plans based on assessments within specified timeframes, but this process was not followed for the resident in question.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident who was frequently incontinent of bladder and bowel did not receive timely incontinence care. The resident, a cognitively intact female with multiple diagnoses including autonomic neuropathy, depression, hypertension, atrial fibrillation, and chronic heart failure, reported not having her incontinence brief changed all morning. She also stated her call light had not worked for two months, and she relied on a bell to alert staff. Record review confirmed her incontinence status, and interviews with staff revealed that the certified nursing assistant (CNA) assigned to her had not changed her since the start of the shift at 6:00am, despite facility policy and staff expectations that incontinence care be provided every two hours or as needed. The CNA reported being responsible for 16 residents and having multiple competing duties, which contributed to the delay in providing care. Both the licensed vocational nurse (LVN) and the director of nursing (DON) confirmed that the facility's expectation was for incontinence care to be provided every two hours or when requested, and that delays could result in skin breakdown, depression, or infection. Facility policy required perineal/incontinent care after each episode of incontinence. The failure to provide timely care was directly observed and confirmed through interviews and record review.
Improper Catheter Bag Positioning During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with an indwelling suprapubic urinary catheter did not receive appropriate catheter care during a transfer from bed to Geri-chair. During the transfer, CNA C placed the catheter drainage bag flat on the foot of the bed, which was above the resident's bladder level, and later hung the bag on the shaft of the mechanical lift. This positioning allowed urine to flow back toward the resident's bladder. The resident required extensive assistance with mobility and had a history of obstructive uropathy and cancer, with moderately impaired cognition. Interviews with CNA C, the Administrator, and the DON confirmed that staff were trained and expected to keep the catheter drainage bag below the bladder to prevent backflow and potential infection. However, the facility's policy on catheter care did not address this specific concern. The failure to maintain the drainage bag below bladder level during the transfer was observed directly and acknowledged by staff as contrary to proper procedure.
Failure to Date Opened Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their only kitchen, as observed during a survey. Specifically, the facility did not ensure that food items, such as liquid eggs, were labeled with use-by dates after being opened. During an observation, it was noted that two packets of liquid eggs in the walk-in refrigerator were opened but lacked a use-by date. Interviews with the Dietary Manager and kitchen staff confirmed that all open food items should have an 'open date' and a 'use-by date,' and that the liquid eggs should have been labeled with a use-by date of three days after opening. The Dietary Manager and staff acknowledged the risk of not dating food items, which could lead to food-borne illnesses among residents. The facility's policy on food storage, revised in February 2024, mandates that all foods be covered, labeled, and dated, aligning with the FDA Food Code requirements. The failure to date opened food items, as per the facility's policy and FDA guidelines, posed a risk of food contamination and illness to residents consuming meals from the facility's kitchen.
Failure to Transmit Discharge MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that discharge Minimum Data Set (MDS) assessments for two residents were electronically completed and transmitted to the CMS System within 14 days after completion. Resident #23, a female who was admitted to the facility and later passed away, did not have a discharge MDS assessment completed, which was identified as being over 120 days late. Similarly, Resident #43, a male who was discharged against medical advice, also lacked a completed discharge MDS assessment, which was also over 120 days late. This oversight was discovered during a review of the residents' records and interviews with facility staff. Interviews with the MDS Nurse and the Regional MDS RN revealed that a change in the electronic health record system in November 2024 contributed to the inability to access previous assessments. The MDS Nurse was responsible for completing all MDS assessments, while the Regional MDS coordinator handled the transmission to CMS. Both staff members acknowledged the requirement to complete and transmit discharge assessments within 14 days of discharge or death. The facility's policy mandates that MDS assessments be conducted and transmitted in a timely manner, but this was not adhered to, leading to incomplete records for the residents involved.
Failure to Include Dialysis in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's need for dialysis, despite the resident being admitted as a dialysis patient. The omission was identified during a survey, and the care plan had not been updated to include dialysis prior to the survey date. The resident, a cognitively intact male with a BIMS score of 15, had been admitted with diagnoses including peripheral vascular disease, hypotension of hemodialysis, muscle wasting and atrophy, and enterocolitis due to clostridium difficile. The Director of Nursing (DON) and the MDS Coordinator acknowledged the oversight, with the MDS Coordinator noting that the care plan should reflect physician orders and the facility's actions for the patient. The facility's policy required the interdisciplinary team to coordinate an appropriate care plan based on assessments within required timeframes.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #30, a male with a history of stroke, hypertension, hyperlipidemia, and anxiety, was totally dependent on staff for personal hygiene. On observation, his fingernails were found to be dirty and jagged, extending 0.4 cm from the tip of his fingers. Resident #30 expressed a desire for his nails to be clipped and cleaned, indicating his dependence on staff for nail care. Similarly, Resident #19, a male with fractures, hypertension, peripheral vascular disease, hyperlipidemia, and schizophrenia, required moderate assistance for personal hygiene. His nails were observed to be long, jagged, and discolored, extending 0.3 cm from the tip of his fingers. Resident #19 also expressed a need for assistance with nail care, noting that his nails had not been clipped for several days. Interviews with facility staff, including a CNA and RN, revealed that both CNAs and nurses were responsible for nail care, which was to be performed on shower days and as needed. The CNA mentioned that Resident #30 sometimes refused nail care, and refusals were reported to the Charge Nurse. The RN acknowledged that dirty, jagged nails could increase the risk of infections. The DON confirmed that nail care was the responsibility of all CNAs and nurses, and nails should be observed daily. The facility's policy on bathing indicated that nail care should be performed to keep nails clean and trimmed. Despite these protocols, the facility failed to ensure that the residents received the necessary nail care, potentially placing them at risk for infections and decreased quality of life.
Improper Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a risk of urinary tract infections. During a wound care procedure, a CNA placed the resident's catheter drainage bag on the bed, above the bladder level, which caused urine to flow back toward the bladder. This action was contrary to the resident's care plan, which specified that the catheter tubing should be kept below the bladder level to prevent complications. Both the CNA and the LVN involved acknowledged the mistake, with the CNA stating she placed the bag on the bed to prevent it from pulling, despite being trained to keep it below the bladder. The resident involved was an elderly male with a history of prostate cancer and a pressure ulcer, requiring extensive assistance with mobility and transfer. His care plan included specific instructions for catheter management to avoid complications. The facility's Director of Nursing confirmed that the improper placement of the catheter bag could lead to urinary tract infections and cross-contamination. Despite the CNA's previous competency check indicating proficiency in catheter care, the facility's policy on catheter care did not address the specific concern of maintaining the drainage bag below bladder level.
Failure to Label Insulin Pen with Open Date
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically regarding the labeling of an insulin pen for a resident. During an observation of the nurses' cart on Hall 600, it was noted that an insulin pen for a resident did not have an open date. The pen was not full and had been used, indicating it was in active use without proper labeling. This oversight was confirmed by LVN A, who admitted to administering insulin from the pen without checking for an open date. LVN A acknowledged the importance of labeling the pen with an open date to ensure the insulin's effectiveness, as it is only viable for 28 days after opening. Further interviews revealed that the Director of Nursing (DON) was aware of the requirement for insulin pens and vials to be dated upon opening, as they have a specific shelf life. The DON stated that the pharmacy consultant conducts monthly checks of the medication carts, and both the DON and Assistant Director of Nursing (ADON) are responsible for performing random checks to monitor compliance. A review of the facility's policy on medication labeling confirmed the necessity of documenting the open date on multi-dose vials to maintain product integrity, aligning with the manufacturer's specifications.
Ineffective Pest Control Program Leads to Bed Bug Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in bed bug sightings on the 600 floor. Two residents reported bed bugs in their rooms, with one resident seeing a bed bug on his bed sheet and another resident's room being treated for bed bugs after a report. The facility's pest control program was not effectively implemented, as evidenced by the lack of comprehensive inspections and staff training on bed bug prevention. Interviews with staff and residents revealed that the facility did not follow its bed bug policy, which required checking all rooms on the affected floor and training staff on bed bug prevention. Some staff members were unaware of the bed bug issue, and there was a lack of documentation and communication regarding the sightings and treatments. The facility's pest control provider was reportedly not thorough, and there were inconsistencies in the pest control treatments and inspections. The facility's pest control policy required immediate notification of the Administrator and Director of Nursing upon realization of a bed bug infestation, but this was not consistently followed. The facility had a history of bed bug issues, and the pest control treatments were not effective in eliminating the problem. The lack of a coordinated response and proper training contributed to the ongoing bed bug issue, which posed a risk to residents' well-being.
Verbal and Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from verbal and mental abuse by a Certified Nursing Assistant (CNA). The incident involved a resident with moderate cognitive impairment and multiple complex medical conditions, including dementia and anxiety. The resident required substantial assistance with daily activities and was observed to have no history of recurrent outbursts or excessive use of the call light until the day of the incident. On the day of the incident, the resident was reportedly on the call light all day and was observed to be anxious. A family member reported witnessing the CNA verbally abusing the resident and forcing her to get out of bed against her will via a video camera in the resident's room. The video footage showed the CNA removing the call light from the resident's hand, refusing to change her when she was wet, and speaking to her in a threatening and disrespectful manner. The CNA was heard making statements that were verbally abusive and dismissive of the resident's needs. The facility's investigation into the incident included reviewing video footage and interviewing staff and the resident. The CNA involved denied the allegations, claiming she was speaking to someone else via earbuds during the incident. However, the video evidence and interviews with the resident and staff indicated that the CNA's behavior was inappropriate and abusive. The facility's policy on abuse and neglect emphasizes the right of residents to be free from abuse and the facility's duty to protect these rights, which was not upheld in this case.
Failure to Maintain Wheelchair Safety
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were maintained and free of hazards for two residents. Resident #2, a male with a history of stroke and high fall risk, was observed in a wheelchair with damaged armrests, exposing jagged edges and metal parts. Multiple staff members, including a medication aide, MDS coordinator, CNA, ADON, and Central Supply Director, were unaware of the condition of the wheelchair, indicating a lack of communication and oversight in maintaining equipment. Resident #3, a female with cognitive deficits and high fall risk, was also found using a wheelchair with torn armrests, exposing the cotton padding. Despite her attempts to address the issue by taping the armrests and speaking to the Maintenance Director, the problem persisted for over a year. Interviews with staff, including the ADON and Maintenance Director, revealed a lack of awareness and a failure to document repair requests in the maintenance log, further highlighting the facility's inadequate system for reporting and addressing equipment maintenance issues. The facility's failure to maintain the wheelchairs in good repair was compounded by the absence of a documented maintenance policy and incident/accident prevention policy, as requested during the survey. The lack of a structured process for identifying and repairing damaged equipment placed residents at risk of injury, as acknowledged by various staff members during interviews. The Administrator and former Administrator were also unaware of any issues with the wheelchairs, indicating a systemic oversight problem within the facility.
Improper Hair Restraint Use by Dietary Staff
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed with Dietary Aide G, who did not properly wear a hair restraint while preparing meals for residents. During an observation, it was noted that Dietary Aide G's hair, approximately 3 inches in length, was not fully covered by the hairnets she wore. She had two small hairnets on either side of her head, leaving the front, sides, and back of her hair exposed. Dietary Aide G admitted to forgetting to put on an additional hairnet due to rushing back from outside to prepare the meal trays. Interviews with other dietary staff and the Dietary Director (DD) revealed that there was an expectation for all hair to be restrained using hairnets to prevent contamination of food. Despite having sufficient hairnets available, the staff did not consistently ensure proper usage. The DD acknowledged the importance of hairnets in maintaining food safety and stated that she would address the issue with Dietary Aide G. The facility's policy and federal food code require effective hair restraints to prevent contamination, but the deficiency in compliance was evident in this instance.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the facility did not complete a weekly skin assessment for a resident from April 14 through April 20, despite the care plan requiring a head-to-toe skin inspection every week. This lapse in care was identified during a record review and interviews with facility staff. The resident involved was an elderly female with a history of urinary tract infection, dementia, absence of the left leg above the knee, and hemiplegia and hemiparesis following a cerebral infarction. The resident had a stage 3 pressure wound on the left ischium, and the lack of a weekly skin assessment could have placed her at risk of receiving inadequate care. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that they were responsible for ensuring the completion of weekly skin assessments, but they missed the audit for the week in question. The facility's policy required weekly skin assessments to prevent pressure ulcers and ensure proper wound care.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of RN D during wound care for a resident. RN D was observed removing gloves and performing hand hygiene with hand sanitizer directly over the resident's open wound on the left ischium. This practice was contrary to infection control protocols, as it posed a risk of micro-organisms or sanitizer contaminating the wound. RN D acknowledged being nervous during the procedure and admitted to not realizing the potential risk of his actions. The resident involved was an elderly female with a history of urinary tract infection, dementia, absence of the left leg above the knee, and hemiplegia and hemiparesis following a cerebral infarction. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed that RN D was trained in proper wound care techniques and understood the risks associated with his actions. The facility's infection prevention and control policy emphasized the importance of preventing contamination during wound care, yet the observed practices did not align with these guidelines.
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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