Spindletop Hill Nursing & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, Texas.
- Location
- 1020 S 23rd St, Beaumont, Texas 77707
- CMS Provider Number
- 455757
- Inspections on file
- 43
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Spindletop Hill Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with COPD and severe cognitive impairment did not receive proper respiratory care when staff failed to replace the nasal cannula and humidifier weekly, and the humidifier was found empty. There was no documentation in the care plan or orders regarding the required maintenance schedule, and facility policy lacked specific oxygen administration requirements. Staff interviews confirmed inconsistent practices and unclear responsibilities.
A resident with Type II diabetes and dementia had inconsistent documentation in the medical record and MAR regarding the blood glucose threshold for holding Novolog insulin. A nurse entered a typographical error in the electronic order, listing the threshold as 200 instead of 100, and this was not promptly corrected. Staff reported using their judgment to hold insulin if BG was less than 100, but the written records did not accurately reflect this practice.
A facility did not report an allegation of neglect involving a resident with multiple complex medical conditions to the State Agency within the required 24-hour timeframe. Although the DON and Administrator were notified and an attempt was made to submit the report, there was no confirmation of receipt, and the report was not found in the system until it was resubmitted several days later.
A facility failed to investigate allegations of abuse and neglect involving two residents. One resident alleged inappropriate advances by a CNA, while another reported an injury during care. The facility did not conduct thorough investigations or report the incidents timely, placing residents at risk. Staff interviews revealed inconsistent reporting and investigation procedures.
The facility failed to report abuse allegations involving two residents to the appropriate authorities within the required timeframe. One resident alleged inappropriate sexual advances by a CNA, which was not reported by the social worker or DON. Another resident reported a leg injury caused by a CNA, but it was not reported as the injury was deemed unintentional. Staff interviews revealed inconsistent reporting and documentation of abuse allegations, placing residents at risk.
Two residents in a facility did not receive their prescribed medications, and the staff failed to notify the physicians as required by policy. One resident missed a dose of Levothyroxine, while another missed multiple medications for various conditions. Interviews revealed that the staff did not follow the protocol of notifying the physician, despite the facility's policy mandating such actions.
The facility failed to administer initial doses of medications to two residents due to a lack of communication and awareness among staff regarding the use of the emergency medication kit (EKit) and alternative pharmacy options. A resident with hypothyroidism missed a dose of Levothyroxine, while another resident with multiple conditions missed several medications. The facility had an EKit available, but it was not utilized, and the responsible staff did not inform the nurse about the unavailability of medications.
A resident with multiple health issues was left in soiled conditions due to delayed incontinent care, despite family grievances. The facility failed to document or address a grievance made in August, as staff were unaware of it. The facility's policy requires prompt grievance resolution, which was not followed.
A resident with multiple medical conditions was left in feces/diarrhea for about an hour, despite a care plan indicating the need for timely care. The DON acknowledged the lapse, and staff interviews revealed a lack of prompt response to a family member's request for care. The facility's perineal care policy was not followed, leading to a deficiency in maintaining personal hygiene.
A resident with dementia and a history of falls was observed biting her hand, but the incident was not documented by the LVN. Later, the resident was found with unexplained injuries, including bruises and swelling, which were not documented or communicated effectively among staff. This lack of documentation and communication placed the resident at risk of not receiving appropriate care.
The facility failed to ensure proper enteral feeding management for two residents, leading to potential nutritional deficiencies and health risks. One resident was repeatedly observed without her feeding tube connected, and another experienced multiple feeding pump errors and unclear orders regarding oral feeding.
The facility failed to maintain sanitary conditions in the kitchen and memory care unit, leading to potential health risks for residents. Observations revealed improper drying of pans, unclean utensils, and untrained staff preparing food in non-designated areas without proper equipment or sanitizing supplies.
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination. An LVN did not use appropriate hand hygiene during medication administration for three residents. Additionally, another LVN used a bottle of formula and tubing that had been left open for 24 hours for a resident receiving enteral feedings. These actions could lead to the spread of infections among residents.
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with multiple diagnoses, including pneumonia, Covid-19, and Parkinson's Disease. The care plan only addressed the resident's CPR status and socialization needs, neglecting other critical aspects of care such as weight monitoring, fall risk, and therapy requirements.
The facility failed to obtain and document a resident's weight on admission as ordered by the physician, resulting in a delay in evaluating the resident's dietary needs. The resident's care plan did not address weight concerns or dietary recommendations, and the Registered Dietician was not provided with the necessary information to assess the resident's nutritional status.
The facility failed to ensure a resident with limited ROM received appropriate treatment, as the resident was observed multiple times without the required hand roll in place. Staff interviews revealed a lack of adherence to physician orders and care plans, and the facility did not provide a policy on ROM and handroll placement when requested.
The facility failed to post Nursing Staffing Data information daily for three days, leading to a lack of posted staffing sheets for May 17th, 18th, and 19th. The staffing coordinator and MOD were unaware of their responsibilities, resulting in non-compliance with the facility's policy.
Failure to Ensure Proper Oxygen Equipment Maintenance and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with COPD, as evidenced by several deficiencies in oxygen administration. Observation revealed that the resident's humidifier was completely empty, and both the nasal cannula and humidifier had not been replaced according to the facility's stated weekly schedule. Documentation review showed that there were no orders or care plan interventions specifying the regular replacement of the nasal cannula or humidifier. Interviews with nursing staff and administration confirmed that the expectation was for these items to be changed weekly, but this was not consistently documented or carried out. The resident, who had severe cognitive impairment and required continuous oxygen therapy, was unaware of the status of his humidifier and could not recall when it was last changed. Staff interviews indicated that the responsibility for changing the equipment was shared among nurses, but there was a lack of clear documentation and adherence to the schedule. Additionally, the facility's policies did not include specific requirements for oxygen administration, and no additional policy could be provided upon request. These findings were based on direct observation, staff interviews, and review of the resident's medical records and facility policies.
Incomplete and Inaccurate Documentation of Insulin Administration Parameters
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately documented, specifically regarding the parameters for holding insulin administration. The resident, who had diagnoses including Type II diabetes and dementia with severe cognitive impairment, had physician orders and MARs that inconsistently documented the blood glucose (BG) threshold for holding Novolog insulin. The physician order and MAR initially stated to hold insulin if BG was less than 200, but nursing staff and the nurse practitioner indicated that the correct threshold should have been 100. A nurse made a typographical error when entering the order into the electronic record, and this discrepancy was not identified or corrected in a timely manner. Despite the error in documentation, nursing staff reported that they consistently held the insulin if the resident's BG was less than 100, following standard nursing judgment rather than the incorrect written order. The facility's policy required that each resident's medical record contain an accurate and complete representation of the resident's care, but the error in the electronic record and MAR resulted in inaccurate documentation of the resident's insulin administration parameters.
Failure to Timely Report Alleged Neglect to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of neglect involving a resident was reported to the State Survey Agency within the required 24-hour timeframe. A family member alleged neglect related to a change in the resident's condition, specifically regarding staff not suctioning the resident. The Director of Nursing was notified of the allegation by an LVN, and the Administrator attempted to submit the report in the TULIP system on the same day. However, there was no confirmation that the report was received, and no intake number was provided. Subsequent review of the facility's TULIP account showed no record of the report being submitted on the required dates. The resident involved was an older male with multiple complex medical conditions, including diabetes, metabolic encephalopathy, aphasia, hemiplegia, hemiparesis following a stroke, dysphagia, and a gastrostomy. Despite the facility's policy requiring follow-up with government agencies to confirm receipt of reports, the Administrator did not verify with the State Agency after the initial submission attempt. The report was ultimately resubmitted several days later, outside the required reporting window.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse and neglect involving two residents. One resident alleged that a CNA made inappropriate sexual advances, while another resident reported that a CNA caused an injury during care. Despite these serious allegations, the facility did not conduct thorough investigations or report the incidents to the appropriate authorities in a timely manner. The first resident, who had a history of making false allegations, claimed that a CNA wanted to engage in inappropriate behavior. The facility's records did not show any investigation into this allegation, and the CNA continued to work at the facility until terminated for unrelated reasons. The second resident reported hearing a pop during care, which was later diagnosed as a chronic fracture. The facility did not suspend the CNA involved or report the incident as required, despite the resident's repeated claims of injury. Interviews with staff revealed a lack of consistent reporting and investigation procedures. Some staff members were unaware of the allegations, while others did not report them due to the residents' histories or perceived lack of intent. The facility's failure to act on these allegations placed residents at risk of further abuse and neglect, as the necessary protective measures were not implemented.
Removal Plan
- Resident #1 was discharged from the facility.
- An Allegation of Abuse was reported to HHSC for Resident #1.
- The Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
- The Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
- Resident #2 was interviewed regarding abuse and neglect with no reports and/or allegations of being abused and/or neglected.
- Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted.
- An allegation of abuse was reported to HHSC for Resident #2.
- The Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The Administrator and/or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified.
- Head to toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment with no concerns identified.
- The Administrator and/or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted.
- The DON/designee reviewed the resident progress notes to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified.
- The DON/Designee reviewed incident/accidents to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified.
- The Administrator and/or Designee reviewed resident grievances to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified.
- The Regional President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation.
- The Administrator/DON and/or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift.
- The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required.
- The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation.
- To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head to toe assessments were completed and provided.
- The Administrator will monitor to ensure new resident incidents are reviewed daily to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided.
- Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation.
- The facility has the Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/concerns will be reported to the Administrator/Abuse Coordinator immediately.
Failure to Report Abuse Allegations in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the appropriate authorities within the required timeframe. One resident alleged that a CNA made inappropriate sexual advances, but the social worker did not report this to the administrator or the Health and Human Services Commission (HHSC). The Director of Nursing (DON) was also aware of the allegation but did not report it, as the resident had a history of making false allegations. The CNA in question continued to work at the facility until he was terminated for unrelated reasons. Another resident reported that a CNA caused a leg injury during care, but the allegation was not reported to HHSC. The resident stated that the injury was not intentional, and the CNA was not suspended or investigated at the time. The DON and the administrator were aware of the incident but did not report it, as they believed there was no intentional harm. The resident later received a diagnosis of a chronic femur fracture. Interviews with staff revealed a lack of consistent reporting and documentation of abuse allegations. The social worker admitted to not documenting or reporting the sexual abuse allegation due to the resident's history of making false claims. The DON and administrator acknowledged the importance of reporting but failed to act promptly. This lack of action placed residents at risk of further abuse and highlighted deficiencies in the facility's abuse reporting procedures.
Removal Plan
- Resident #1 was discharged from the facility.
- An Allegation of Abuse was reported to HHSC for Resident #1.
- The LBSW Social Worker was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
- The Director of Nursing was suspended pending investigation outcome related to the allegation of sexual abuse for Resident #1.
- Resident #2 was interviewed regarding abuse and neglect with no reports and/or allegations of being abused and/or neglected.
- Resident #2 was reassessed head to toe by the License Nurse related to abuse and neglect with no concerns noted.
- An allegation of abuse was reported to HHSC for Resident #2.
- The Director of Nursing was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The Administrator was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The C.N.A. Resident #2 reported provided care at the time of the incident was suspended pending investigation outcome related to the allegation of abuse for Resident #2.
- The Administrator and/or designee completed 100% of interviews of interviewable residents to assess for potential abuse, neglect, mistreatment, and misappropriation. Findings: No additional concerns were identified.
- Head-to-toe assessments were completed by the Licensed Nurse on residents with a BIMS below 12 to identify any signs of injuries of unknown source and/or evidence of abuse, neglect and mistreatment with no concerns identified.
- The Administrator and/or designee completed staff interviews with all staff to identify concerns related to abuse, neglect, mistreatment, and misappropriation with no concerns noted.
- The DON/designee reviewed the resident progress notes to ensure concerns related to abuse, neglect, mistreatment and/or misappropriation were identified, reported to HHSC and an investigation initiated with appropriate staff suspension. Findings: No additional concerns were identified.
- The DON/Designee reviewed incident/accidents to ensure that investigations, timely reporting to HHSC as indicated with appropriate staff suspension, and resident assessments to include head to toe assessments were completed. Findings: No additional concerns were identified.
- The Administrator and/or Designee reviewed resident grievances to ensure that grievances were investigated and reported timely to HHSC as indicated with appropriate staff suspension(s). Findings: No additional concerns were identified.
- The Regional President of Operations and Regional Clinical Specialist reeducated the Administrator (Abuse Coordinator) and Director of Nursing on Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as timely initiation of the investigation into the allegation. Reeducation included immediate identification and suspension of all personnel suspected to be involved in the allegation.
- The Administrator/DON and/or designee began reeducation to 100% of facility staff on the following: On Abuse and Neglect and Abuse Policy to include criteria for reporting, timely reporting, and reporting timeframes; as well as resident protection with examples provided. Employees were reeducated on the facility investigation process which includes immediate identification and suspension of all personnel suspected to be involved in the allegation. Facility staff were reeducated the Abuse Coordinator and the Abuse Coordinator's role, as well as the Abuse Coordinator's contact information and where this information is located. Staff were reeducated on notifying the Director of Nursing, their immediate supervisor and/or regional staff if they are unable to reach the abuse coordinator.
- Any facility staff on FMLA, Leave of Absence, non-scheduled workday or PTO will be reeducated by the Administrator and/or designee prior to the start of their next scheduled shift.
- The facility maintains an onsite Weekend Manager and Nursing Supervisor that conduct rounds and may initiate and address resident incidents and will escalate to the appropriate administrative staff when required.
- The Administrator who is the Abuse Prevention Coordinator will be immediately notified for any concerns with Abuse, Neglect and Misappropriation.
- To monitor, the Administrator and/or designee and Director of Nursing/designee will review the 24-hour report, resident incidents, and grievances in facility Stand-up Morning Meeting, attended Monday-Friday. 24 Hour Report and resident incidents will be reviewed for potential abuse situations and need for reporting as per HHSC guidelines. Review will also include ensuring investigation, resident assessments to include a head-to-toe assessments were completed and provided.
- The Administrator will monitor to ensure new resident incidents are reviewed daily Monday-Friday to ensure concerns are addressed timely and if necessary, reported per HHSC guidelines, investigation was completed, resident assessments were completed and provided.
- Administrator/designee will conduct quarterly and as needed on Abuse, Neglect, & Exploitation education to ensure facility staff remains knowledgeable on the identification and reporting of abuse/neglect/exploitation.
- The facility has the Ambassador Rounds Program in place where administrative staff is assigned to residents. Staff will round and visit to ensure resident wellness and safety. Findings/concerns will be reported to the Administrator/Abuse Coordinator immediately.
- An AdHoc QAPI was conducted, attended by the Administrator, DON, Medical Director, and Regional Clinical Specialist to discuss the Immediate Jeopardy concerning F 609 - Immediate reporting of allegations of abuse, neglect, and exploitation and misappropriation of resident property and develop the above Action Plan.
Failure to Notify Physicians of Missed Medication Doses
Penalty
Summary
The facility failed to consult with the residents' physicians when there was a need to alter treatment for two residents. Resident #3, an elderly female with hypothyroidism, did not receive her prescribed dose of Levothyroxine on a specific date in May 2024. The nursing notes lacked documentation indicating that the physician was notified about the missed dose. Similarly, Resident #4, an elderly female with multiple diagnoses including methemoglobinemia, hypertension, depression, and GERD, did not receive several prescribed medications on a specific date in September 2024. Again, there was no documentation in the nursing notes that the physician was informed about the missed doses. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the facility's staff did not follow the expected protocol of notifying the physician when medications were unavailable for administration. The DON expressed confusion as to why the staff did not notify the physician, acknowledging that the residents could experience a decline in health. The facility's policy on Notification of Changes, dated October 2022, mandates prompt consultation with the resident's physician and notification of the resident's representative when there is a change requiring notification. Despite the physician's statement that missing the doses would not cause adverse effects, the lack of notification was a clear deviation from the facility's policy.
Failure to Administer Initial Doses of Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents, resulting in missed initial doses of prescribed medications. Resident #3, a female with hypothyroidism, did not receive her prescribed Levothyroxine dose on May 21, 2024. The medication administration record (MAR) indicated the dose was not given, and attempts to contact the responsible LVN were unsuccessful. Resident #4, a female with multiple diagnoses including methemoglobinemia, hypertension, depression, and GERD, did not receive several prescribed medications on September 17, 2024. These medications included Carvedilol, Ferrous Sulfate, Hydralazine, Montelukast, Nifedipine, Protonix, and Sertraline. The MAR showed these doses were not administered, and the medication aide (MA) involved did not inform the nurse about the unavailability of the medications. Interviews with facility staff revealed that the facility had an emergency medication kit (EKit) available, which contained some of the required medications. The Director of Nursing (DON) and other staff members indicated that the EKit should have been used if the pharmacy had not delivered the medications. However, there was a lack of communication and awareness among staff regarding the use of the EKit and alternative pharmacy options, leading to the failure to administer the necessary medications to the residents.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for a resident, as evidenced by the lack of thorough investigation or timely action regarding complaints made by the resident's family member. The resident, a female with multiple diagnoses including cerebral infarction, muscle wasting, hemiplegia, seizures, end-stage renal disease, heart failure, and stomach cancer, was dependent on assistance for personal care and was always incontinent of bladder and bowel. The resident's care plan highlighted the risk of impaired skin integrity due to incontinence, with interventions including timely incontinent care. A grievance was recorded on September 3rd, 2024, when a family member reported that the resident was not changed after a request was made to the nurse. The investigation revealed that staff were occupied with passing trays and assisting residents with dinner, delaying the resident's care. The resolution involved a plan to check the resident before meals to ensure timely care, which satisfied the family member. However, there was no grievance report available for August 2024, despite a family member's claim of making a grievance that month regarding the resident being left in feces. Interviews with facility staff, including the Administrator, Social Worker, Admissions Coordinator, and Director of Nursing, revealed a lack of awareness or recall of the August grievance. The facility's policy requires prompt efforts to resolve grievances, including acknowledgment, investigation, and communication of findings to the complainant. The absence of a documented grievance for August 2024 and the staff's lack of awareness indicate a failure to adhere to this policy, potentially leaving grievances unaddressed.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to a resident, leading to a deficiency in maintaining personal hygiene. The resident, who had multiple medical conditions including cerebral infarction, muscle wasting, hemiplegia, and end-stage renal disease, was left in feces/diarrhea for approximately one hour. This incident occurred despite the resident's care plan indicating a risk of impaired skin integrity due to incontinence and the need for timely care. The Director of Nursing (DON) acknowledged that the resident should not have been left in such a condition and emphasized that residents should be checked and changed every two hours and as needed. Observations and interviews revealed that a family member informed an LVN about the resident's need for care, but the care was not provided promptly. A family member later found the resident still in a soiled state, and a picture was submitted to the state surveyor showing the extent of the issue. Staff interviews indicated a lack of recall or acknowledgment of the request for care, and the facility's perineal care policy was not adhered to, which mandates providing care to prevent infection and skin breakdown.
Failure to Document Resident's Condition and Injuries
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for a resident reviewed for accuracy of clinical records. The deficiency involved a lack of documentation by LVN A regarding an incident on 08/02/24, where the resident was observed biting her right hand. Despite being informed of this behavior by DR/OT B, LVN A did not document her assessment or any follow-up actions in the electronic health record (EHR). This omission was significant as the resident was later observed with injuries of unknown origin, including a bruise and scratches on her right hand and wrist, and edema around her right eye and forehead. The resident, who had a history of dementia, muscle wasting, contractures, and repeated falls, was dependent on others for all activities of daily living and mobility. On 08/05/24, the resident was found with a knot on her forehead, fluid pocket around her right eye, and bruising and scratches on her right wrist. Despite these findings, there was no documentation of any falls or incidents that could have caused these injuries. The lack of documentation and communication among staff members regarding the resident's condition and potential need for pain management contributed to the deficiency. Interviews with facility staff revealed inconsistencies in the reporting and documentation of the resident's condition. The DON and other staff members were not aware of the resident's self-injurious behavior or the subsequent injuries until they were observed by hospice staff. The facility's policy required timely and accurate documentation of assessments and observations, which was not adhered to in this case. This failure to document and communicate effectively placed the resident at risk of not receiving appropriate care and services to meet her needs.
Failure to Ensure Proper Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Resident #44, a female with severe cognitive impairment and dysphagia, was observed multiple times without her feeding tube connected and the feeding pump turned off, despite physician orders for continuous feeding with Jevity 1.5 at 65ml/hour. This indicates a failure to adhere to the prescribed feeding schedule, potentially compromising her nutritional intake and overall health. Resident #89, a male with a history of traumatic brain injury and chronic respiratory failure, also experienced issues with his enteral feeding. His feeding pump was observed to be in a state of alarm due to flow errors on multiple occasions, and there were instances where the pump was turned off without a clear physician order. Interviews with various LVNs revealed confusion and lack of clarity regarding the orders for turning off the enteral feeding, indicating a breakdown in communication and adherence to physician directives. The Director of Nursing (DON) was unable to provide a clear explanation for the feeding pump issues and could not locate a new dietary order from the Registered Dietitian. The facility also failed to provide a policy on enteral feeding before the survey exit. These deficiencies in managing enteral feeding for Residents #44 and #89 highlight significant lapses in ensuring proper nutrition and care for residents with feeding tubes, potentially leading to adverse health outcomes.
Failure to Maintain Sanitary Food Storage and Preparation Conditions
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Observations revealed that sixteen stainless steel steam table pans were stacked wet on the pan storage rack, and a cook used a paper drying cloth to dry pans that were supposed to air dry. Additionally, a serving utensil containing dried food debris was found on the serving line. The dietary manager acknowledged these issues and provided documentation of staff training on the proper use of the 3-compartment sink and air drying of dishes. However, further observations showed that staff continued to improperly dry pans with paper towels, and a utensil with dried food debris was placed on the steam table for service before being noticed and removed for re-washing. The facility's policy and FDA Food Code require that equipment and utensils be air-dried to prevent re-contamination, which was not consistently followed in this case. In the memory care unit, untrained staff were observed making peanut butter and jelly sandwiches in a non-designated food preparation area without proper equipment or sanitizing supplies. The staff member did not wear a hair net or apron, used a shampoo and body wash solution to wash hands, and did not sanitize the countertop before preparing the sandwiches. The bread used for the sandwiches was not labeled with an initial open use date. Interviews with staff revealed that the kitchen did not consistently provide snacks for the memory unit, leading to untrained staff making sandwiches for residents. The dietary manager admitted that the decision to have the memory unit staff make their own snacks was due to the high wastage of pre-made sandwiches and acknowledged that the area used for sandwich preparation was not adequately equipped or sanitized. The facility's failure to ensure proper food storage, preparation, and distribution practices, as well as the lack of training and certification for staff preparing food in the memory unit, could place residents at risk of foodborne illness. The dietary manager and other staff members were aware of the issues but did not take adequate steps to address them, resulting in unsanitary conditions and potential health risks for residents consuming the food prepared under these conditions.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination and the spread of infection among residents. During medication administration, an LVN did not use appropriate hand hygiene practices. The LVN was observed administering medications to three residents without sanitizing her hands before and after each task, despite touching various items and residents. This failure was acknowledged by the LVN and the DON, who confirmed that proper hand hygiene is crucial for infection control. Additionally, the facility did not ensure proper handling of enteral feeding equipment. An LVN used a bottle of formula and tubing that had been left open and uncovered for approximately 24 hours. The LVN admitted to not obtaining a new bottle of formula or new tubing, which should have been done to prevent contamination. The DON and a Nurse Consultant confirmed that the facility lacked a specific policy for enteral feedings, although the manufacturer's instructions indicated that an opened bottle of formula could hang for up to 48 hours. The deficiencies involved four residents with serious medical conditions, including infections and surgical interventions. The lack of proper hand hygiene and the improper handling of enteral feeding equipment could lead to the transmission of infections, posing significant risks to the residents' health and safety.
Failure to Develop and Implement Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, which included the necessary instructions to provide effective and person-centered care. The resident, an elderly male, was admitted with multiple diagnoses including pneumonia, Covid-19, dehydration, Parkinson's Disease, dysphagia, generalized weakness, and vitamin deficiency. Despite these complex medical conditions, the baseline care plan only addressed the resident's cardiopulmonary resuscitation status and dependency on staff for socialization and activity needs, neglecting other critical aspects of his care such as weight monitoring, fall risk, ambulation needs, and therapy requirements. The Director of Nursing (DON) acknowledged that the baseline care plan was incomplete and confirmed that it was her responsibility to ensure its completion. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including initial goals based on admission orders and physician directives. However, the care plan for this resident did not address his admitting diagnoses, physician orders, or risk assessments for falls, pressure ulcers, and pain, thereby placing the resident at risk of receiving inadequate care and services.
Failure to Obtain and Document Resident's Weight on Admission
Penalty
Summary
The facility failed to ensure that Resident #360 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not obtain the resident's weight on admission as ordered by the physician. The resident, a male with a history of dehydration, dysphagia, generalized weakness, and vitamin deficiency, was admitted with additional diagnoses of Covid-19, pneumonia, and dehydration. Despite physician orders to weigh the resident on admission and weekly thereafter, the initial weight was not documented in the computerized medical record, nor was it communicated to the Registered Dietician. The resident's care plan also did not address weight concerns or dietary recommendations, despite the resident's frail and malnourished condition upon admission. The Restorative Aide, responsible for weighing residents, indicated that the weight was taken five days after admission but was not entered into the computer system due to being frequently pulled to assist on the floor when the facility was short-staffed. This delay and lack of documentation resulted in the Registered Dietician not having the necessary information to evaluate the resident's dietary needs. During interviews, the DON acknowledged the failure to comply with the physician's order for weighing the resident on admission and recognized the potential impact of this failure on the resident's care. The discrepancy in weights taken on different dates was attributed to the use of different scales (wheelchair vs. bed scales). The facility's policy on weight monitoring emphasized the importance of obtaining and recording weights upon admission to assess nutritional risk, but this policy was not followed in the case of Resident #360. The failure to obtain and document the resident's weight as ordered could lead to delays or absence of necessary care and services to prevent weight loss.
Failure to Provide Appropriate ROM Treatment
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase their range of motion and to prevent further decrease. Specifically, the facility did not place hand rolls and/or positioning devices in the resident's right hand as ordered by the physician. The resident, a [AGE] year-old female with diagnoses including contracture of the right hand, muscle wasting, and unspecified dementia, was observed multiple times without the required hand roll in place. This was despite physician orders indicating the need for a hand roll every shift and the care plan addressing the contractures of the right hand. The treatment administration record also indicated that the resident should have had a hand roll in place, but observations on several occasions showed otherwise. Interviews with staff, including the ADON and a CNA, revealed that it was everyone's responsibility to ensure the hand rolls were in place, yet the CNA admitted to not placing any hand rolls for the resident. Additionally, the facility did not provide a policy on Range of Motion and placement of handrolls/splints when requested. This lack of adherence to the care plan and physician orders could place the resident at risk of not receiving the appropriate care and services to maintain their highest level of well-being.
Failure to Post Daily Nursing Staffing Data
Penalty
Summary
The facility failed to post Nursing Staffing Data information daily as required for three of the four days reviewed. Specifically, the facility did not post the total number of hours worked for licensed nurses and certified nurse aides or the daily census for May 17th, 18th, and 19th of 2024. During an observation on May 20th, the staffing sheet posted was dated May 16th in the morning and May 20th in the afternoon. Interviews revealed that the staffing coordinator, who worked Monday through Friday, did not have the staffing sheets for the missing dates and was unaware of who was responsible for posting them on weekends. The Administrator confirmed that the MOD was responsible for posting the sheets on weekends, but the BOM, who served as the MOD on weekends, was not informed of this responsibility and thus did not post the sheets. Record review of the facility's staffing sheets for May 2024 indicated there were no documented staffing sheets on May 17th, 18th, and 19th. The facility's Nurse Staffing Posting Information policy, dated October 24, 2022, stated that nurse staffing information should be made readily available in a readable format to residents and visitors at any given time and that the Nurse Staffing Sheet should be posted daily at the beginning of each shift. The Administrator was unaware that the staffing sheets were not being posted on weekends and expected the staffing to be posted daily to assure residents and family members of adequate staffing.
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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