St. Joseph Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Bryan, Texas.
- Location
- 2333 Manor Dr, Bryan, Texas 77802
- CMS Provider Number
- 675887
- Inspections on file
- 33
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 11 (2 serious)
Citation history
Health deficiencies cited at St. Joseph Manor during CMS and state inspections, most recent first.
A resident with Ogilvie syndrome and a care plan for altered GI status did not consistently receive ordered bowel medications, including bisacodyl suppositories, lactobacillus, and polyethylene glycol. MARs and nursing notes showed multiple missed doses documented as "on order" or "on reorder," while the resident and the resident’s representative reported ongoing problems with medications running out. A medication aide described a weekly OTC ordering process that could delay obtaining needed OTC drugs, and the DON acknowledged that the resident’s suppositories were not on the current order list despite policies requiring accurate ordering, reordering, and timely administration of medications as prescribed.
A resident with dementia, diabetes, and hypertension, who required significant ADL assistance and had impaired coping, was financially exploited when a CNA took the resident’s debit card and made numerous unauthorized purchases at various stores and gas stations. The resident’s POA discovered the suspicious charges on the card statements, reported them to law enforcement, and did not initially inform facility staff, stating police advised against it and that the facility did not receive the statements. The CNA, whose pre-employment criminal history check showed no disqualifying offenses, was later terminated for no call/no show and subsequently arrested. The facility’s policy stated residents’ rights to be free from abuse, exploitation, and misappropriation and required protocols to prevent and identify theft and to screen employees for abuse- or misappropriation-related findings.
A resident with cognitive intactness and multiple medical conditions, including hemiplegia and a history of cerebral infarction, had a care plan for inadequate nourishment that included therapeutic supplements and a physician order for Ensure Clear with the noon meal. Despite this, the resident reported not receiving the supplement, and surveyor observation of a lunch tray confirmed its absence. The resident’s representative stated she had repeatedly raised the issue at care plan meetings, and the SW recalled being told about the need for Ensure Clear but did not verify follow‑through. The DON was unaware the supplement was not being given, even though facility policy requires medications and ordered items to be administered as prescribed.
A resident with a PICC line did not have her dressing changed according to physician orders and facility policy, despite documentation by an LVN indicating the task was completed. The DON confirmed the dressing was not changed as required, and the discrepancy was identified through observation and record review.
Expired bottles of Melatonin 1mg and Aspirin 325mg were found on a medication cart during a survey. An LVN acknowledged responsibility for removing expired medications in the absence of a medication aide, and the DON confirmed staff are expected to check for expired drugs before administration. The facility's policy requires nursing staff to maintain medication storage and remove outdated medications, but these expired drugs remained on the cart.
A medication cart was found with a bottle of lactulose that was sticky and adhered to the drawer, indicating improper storage and lack of cleanliness. An LVN acknowledged the issue, and the DON stated that staff are responsible for ensuring medications are stored properly, as outlined in facility policy.
A resident with a stasis ulcer did not receive wound care in accordance with infection control protocols when an LVN failed to perform hand hygiene before and between glove changes, used gloves stored in a scrub pocket, and did not clean the overbed table before placing supplies. Both the LVN and DON confirmed these actions did not follow facility policy.
A deficiency was cited when a resident was found to have been prescribed or administered unnecessary drugs, with no adequate clinical justification documented in the medical record.
The facility did not ensure that laboratory services or tests were provided in a timely and quality manner to meet resident needs, as identified by surveyors.
Nurse staffing information, including the number and hours worked by RNs, LPNs, and CNAs, as well as the facility name, date, and resident census, was not posted as required. Staff schedules were available in a lobby binder but did not meet regulatory requirements, and staff interviews revealed confusion about the posting process and responsibilities.
A resident prescribed Modafinil for sleep apnea did not receive the medication after it was delivered and signed for by nursing staff. The medication and its count sheet went missing after two nurses failed to perform the required shift change narcotic count, with both nurses admitting to not following facility policy for controlled substance accountability. The medication was never found, and the required procedures for receiving, recording, and securing controlled substances were not followed.
Several residents with complex medical needs did not have complete or accurate documentation of medication, treatment, and wound care administration. MARs, TARs, WARs, and Controlled Drug Records were missing or inconsistent, and staff interviews revealed confusion and lapses in following documentation procedures. The facility's narcotic record logs were also disorganized, with missing records for discontinued medications and discharged residents.
Three residents did not have comprehensive, individualized care plans addressing their specific needs, including refusal of monthly weights, refusal to sit upright during meals, and use of respiratory equipment. Care plans lacked documentation of refusals, individualized interventions, and necessary physician orders, resulting in unmet care needs.
Three dependent residents did not receive scheduled showers as required by their care plans, with missing or inaccurate documentation in both EHR and paper records. Staff interviews revealed inconsistent documentation practices and short staffing, leading to missed bathing care and resident dissatisfaction.
Multiple nourishment room refrigerators were found without required temperature logs, contained expired food items, and showed evidence of poor sanitation, including stains, a human hair, and pest activity. Staff interviews revealed confusion over responsibilities for cleaning and monitoring, and a review of the facility's contract confirmed divided duties between the facility and the contracted kitchen.
Two residents did not have their comprehensive admission MDS assessments completed within the required 14-day period. Both assessments were overdue, with one resident's assessment 2 days late and the other 9 days late. Staffing challenges and workload issues among MDS coordinators contributed to the delay, and the facility did not provide a policy on timely MDS completion when requested.
A resident with dementia and moderate cognitive impairment was not properly assisted or positioned to eat her meal in bed, leaving her unable to reach or see her food. Staff were unclear about who placed the tray, and the resident's care plan required assistance with eating, which was not provided according to facility policy.
A medication aide failed to confirm that a resident with impaired cognition and swallowing difficulties consumed her nighttime medications, resulting in unconsumed pills being found in the resident's room. The aide was unaware of a physician's order to crush medications, and staff were not informed of the resident's difficulty swallowing, leading to a lapse in medication administration according to professional standards.
A resident with multiple chronic conditions was using a CPAP machine nightly and a nebulizer as needed, but there were no physician's orders or care plan interventions documented for either device. Nursing staff confirmed the use of these devices without proper documentation, and there was no record of equipment maintenance or cleaning schedules.
A resident with multiple medical conditions did not receive prescribed Thiamine and Ergocalciferol because these medications were not available at the time of administration. Staff interviews revealed inconsistent communication and unclear procedures regarding reporting and obtaining unavailable medications, and no policy on medication availability was provided during the survey.
A medication error rate above 5% was identified when a resident with complex medical needs did not receive prescribed Thiamine and Ergocalciferol because the medications were not available. The medication aide reported the issue to a nurse, but the nurse was unaware of the shortage, leading to missed doses and a failure to follow facility policy for medication administration and communication.
A medication aide left a medication cart unlocked and unattended in a hallway, with over-the-counter medications left out on top of the cart while administering medications in a resident's room. The aide acknowledged that the cart should not be left unlocked or with medications exposed, and the DON confirmed that staff are expected to keep carts locked unless in use, as per facility policy.
A medication aide did not perform hand hygiene or wear gloves before and after administering prescribed eye drops to a resident with multiple medical conditions, including sepsis and glaucoma. This lapse was observed by surveyors, and the aide later acknowledged the failure to follow infection control procedures, which are required by facility policy and staff training.
The facility failed to assess and obtain informed consent for bed rail use for three residents, leading to potential risks of entrapment and injury. Observations showed residents with side rails up, but records lacked documentation of care plans, physician orders, and risk assessments. Interviews revealed that bed rails were used as enablers without proper consent or assessment, contrary to facility policy.
The facility failed to notify residents of a change in their attending physician after terminating the Medical Director's agreement. This affected several residents, who were not informed about the change, leading to a lack of choice in their medical care. The administration admitted the oversight, but there was no evidence of proper notification being distributed.
A resident's medications were left unsecured on a medication cart, and a loose pill was improperly disposed of in a trash can. The facility's policies require medications to be locked or attended by staff and disposed of in a sharps container. Staff interviews confirmed these expectations, but additional policies were not provided during the survey.
A resident was found with a bleeding head wound less than 24 hours after admission, but the facility failed to report the incident to the state agency within the required 24-hour timeframe. The delay occurred because the administrator waited for corporate approval before reporting.
Failure to Ensure Continuous Availability and Administration of Ordered Medications for Bowel Management
Penalty
Summary
Surveyors identified a failure to provide pharmaceutical services to meet the needs of a resident with Ogilvie syndrome, hemiplegia, and hemiparesis following a cerebral infarction. The resident was cognitively intact per a recent MDS and had a care plan focus on altered gastrointestinal status related to Ogilvie syndrome, with interventions including administering medications as ordered and monitoring side effects and effectiveness. Physician orders included bisacodyl rectal suppository 10 mg daily, lactobacillus two tablets by mouth daily, and polyethylene glycol 17 grams by mouth twice daily. Record review of the MAR showed that the resident did not receive lactobacillus for several consecutive days, did not receive polyethylene glycol on two days, and did not receive the ordered bisacodyl suppository on another day. Nursing progress notes documented that lactobacillus and polyethylene glycol were not administered because they were "on order" and that the bisacodyl suppository was not administered because it was "on reorder." The resident reported he was not getting his constipation medications consistently, stated he had run out of medications, and specifically noted he did not receive his suppository the previous night because staff told him they had run out. The resident’s responsible party reported that running out of the resident’s medications had been an ongoing problem and that he had missed multiple doses of lactobacillus, polyethylene glycol, and bisacodyl suppositories. A medication aide stated that the resident’s polyethylene glycol and probiotic were OTC medications and explained that OTC orders had to be submitted to the DON on a specific day of the week, with delivery occurring later, and that missing the weekly order meant waiting until the next week. The DON stated that OTCs were ordered a week ahead, that the facility had a contract with a local pharmacy that could supply OTCs, and that residents should not run out of medications, while acknowledging that the resident’s suppositories were not on the current week’s delivery list. Facility policies required accurate documentation and management of medication ordering, reordering, dispensing, and receipt through the EHR, and required medications to be administered in a safe and timely manner as prescribed.
Failure to Protect Resident From Financial Exploitation and Misappropriation of Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from exploitation and misappropriation of property by a CNA. The resident was an elderly female with dementia, diabetes mellitus, and hypertension, admitted with severe cognitive impairment as evidenced by a BIMS score of six and requiring partial to substantial assistance with all ADLs. Her care plan included interventions for impaired coping, such as encouraging rest and involving the resident or representative in determining next steps in care. Despite these needs and vulnerabilities, a CNA employed at the facility from late October to early December took the resident’s debit card at some point during her employment and used it for personal purchases. Law enforcement records reviewed by surveyors indicated that the CNA allegedly committed financial exploitation of the resident over a period of several months, resulting in at least 36 unauthorized charges on the resident’s debit card at liquor stores, grocery stores, and gas stations in multiple cities. The exact dollar amount was not yet determined because the matter remained under investigation. The CNA’s criminal history check, completed prior to hire, did not reveal any disqualifying offenses, and the facility’s records showed she was terminated for no call/no show, with no documented complaints about her performance while employed. The resident’s responsible party, who held power of attorney and received the debit card statements, discovered numerous charges that the resident could not have made and reported the matter directly to law enforcement without informing the facility, stating that police advised him not to notify the facility until further investigation. He also stated that the facility could not have known about the charges because the statements were sent only to him. The facility became aware of the alleged misappropriation when it received a subpoena from a detective requesting employment and termination records for the CNA. At the time of surveyor observation and interview, the resident did not voice complaints about staff treatment or missing personal items. The facility’s written policy stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the facility would develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of resident property and conduct background checks to avoid employing individuals with findings related to abuse or misappropriation.
Failure to Provide Physician‑Ordered Nutritional Supplement at Lunch
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered nutritional supplement to a resident with identified nutritional concerns. The resident, who had diagnoses including Ogilvie syndrome, hemiplegia and hemiparesis following a cerebral infarction, had a comprehensive care plan focus area for "state of nourishment, less than body requirement" characterized by weight loss, inadequate intake, and decreased appetite, with interventions that included providing therapeutic supplements. The consolidated physician orders included an order for Ensure Clear with the noon/lunch meal once daily. Despite this, observation of the resident’s lunch tray showed no supplement present, and the resident reported that he was supposed to receive a supplement at lunch but that staff never gave it to him. The resident’s responsible party reported that the resident was not receiving his Ensure Clear as ordered and stated she had raised this concern at the last two care plan meetings, including one documented meeting where the care plan noted the need for clear Ensure. The social worker confirmed remembering the family’s report about the Ensure Clear and stated she believed she had passed the information on to nursing but did not follow up to ensure the supplement was provided. The DON stated she was not aware the resident was not receiving the ordered supplement and indicated there was no reason the supplement should not have been provided if ordered. The facility’s provided policy on administering medication stated that medications are to be administered in a safe and timely manner and as prescribed, but the resident’s ordered supplement was not administered with his lunch as required.
Failure to Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for one resident. The resident, a cognitively intact female with a history of Staphylococcal arthritis, sepsis, and methicillin-susceptible staphylococcus aureus infection, was admitted with orders for IV medication and a peripherally inserted central catheter (PICC) line. The care plan required weekly monitoring and dressing changes for the PICC line, and physician orders specified that the dressing should be changed every week and as needed. Upon review, it was found that the resident's PICC line dressing was dated eight days prior to the observation, despite documentation indicating that the dressing had been changed as scheduled. The dressing was signed off as changed by an LVN, but direct observation and the date on the dressing indicated that the change had not actually occurred. The DON confirmed that the dressing had not been changed as required and that it was inappropriate for staff to document completion of a task that was not performed. Facility policy also required dressing changes at least every seven days to prevent complications, but this was not followed in this instance.
Expired Medications Found on Medication Cart
Penalty
Summary
Expired medications were found on the station one medication cart during an observation, specifically one bottle of Melatonin 1mg and one bottle of Aspirin 325mg, both expired as of 08/2025. The facility's policy requires nursing staff to maintain medication storage areas and ensure that discontinued, outdated, or deteriorated medications are removed and handled according to pharmacy instructions. However, these expired medications remained on the cart past their expiration date. During interviews, an LVN stated that it was the medication aide's responsibility to ensure expired medications were not present, but since there was no medication aide at the time, the LVN acknowledged it was his responsibility while passing medications. The DON confirmed that both medications were expired and stated that staff are expected to check medications prior to administration to ensure they are not expired. The presence of expired medications on the cart indicated a failure to follow established procedures for medication management.
Failure to Maintain Clean and Orderly Medication Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and cleanliness of drugs and biologicals on one of four medication carts reviewed. Specifically, a bottle of lactulose was found in the medication cart drawer with sticky residue on its sides, and the bottle was stuck to the bottom of the drawer. During interviews, an LVN acknowledged that the bottle was sticky and should have been cleaned, and the DON confirmed that staff are expected to check medications prior to administration to ensure proper storage. Review of the facility's medication labeling and storage policy indicated that medications should be stored in an orderly manner and that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary condition. The observed failure to maintain cleanliness and orderliness in the medication cart drawer directly contradicted the facility's policy and could affect the integrity of medications stored within.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with a right lower extremity (RLE) stasis ulcer. During wound care, an LVN did not perform hand hygiene prior to the procedure, between glove changes, or after glove removal. The LVN also used gloves that had been stored in the pocket of his scrub pants, which were considered contaminated, and did not clean the overbed table before placing treatment supplies on it. These actions were observed during a wound care procedure, and the LVN acknowledged not following proper hand hygiene protocols and not ensuring a clean field for the supplies. The resident involved was an older female with diagnoses including alcohol dependence, major depression, and muscle wasting, and had a care plan for potential impaired skin integrity. Physician orders required specific wound care procedures, including cleansing and dressing changes. Facility policies on hand hygiene and wound care were reviewed, which outlined the need for handwashing before resident contact, between glove changes, and after glove removal, as well as the use of a clean field for supplies. The LVN and DON both confirmed that the observed practices did not align with facility policy.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Provide Timely, Quality Laboratory Services
Penalty
Summary
The facility failed to provide timely and quality laboratory services or tests to meet the needs of residents. This deficiency was identified through surveyor observation and review of facility practices, indicating that laboratory services were not delivered in a manner that met the required standards for resident care. No additional details regarding specific residents, their medical history, or the exact nature of the laboratory service delays or deficiencies are provided in the report.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was properly posted as required. On the day reviewed, there was no posted nurse staffing information in the building, including in the lobby, nurse's stations, or hallways. Although a binder containing staff schedules was present in the front lobby, it did not include the required details such as the total number and actual hours worked by registered nurses, licensed practical/vocational nurses, and certified nurse aides for each shift, nor did it include the facility name, current date, or resident census. Multiple locations were checked, and the required posting was not found. Interviews with facility staff revealed a lack of understanding and awareness regarding the nurse staffing posting requirements. The DON believed the schedule binder met the requirement and was unaware of the specific posting obligations or how to generate the necessary report from the electronic system. The RNC was aware of the requirement but did not realize the facility was not in compliance, and confirmed that the schedule binder did not meet the requirement. The facility's policy stated that nurse staffing information should be posted daily in a clear and accessible format, but this was not followed.
Failure to Account for and Secure Controlled Substance Due to Missed Shift Change Narcotic Count
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident. Specifically, a resident with diagnoses including sleep apnea, morbid obesity, and epilepsy was prescribed Modafinil 100 mg tablets for sleepiness related to sleep apnea. The medication, consisting of 30 tablets, was delivered by the pharmacy and signed for by a nurse, but was never administered to the resident and was reported missing the following day. The investigation revealed that the medication was received by one nurse and handed over to another, who reported placing it in the narcotic storage box with the pharmacy's count sheet. However, during the subsequent shift change, the required narcotic count was not performed by the two nurses responsible. Both nurses admitted in interviews that they did not count the narcotics together at shift change, contrary to facility policy. One nurse stated she counted the narcotics alone, while the other left the cart keys in the narcotic book and did not participate in the count. The medication and the count sheet were subsequently discovered missing, and a search of all medication carts and rooms failed to locate the missing Modafinil. Facility records and interviews confirmed that the required procedures for controlled substance accountability were not followed. The facility's policy mandates that controlled substances be signed for by two nurses, immediately recorded, and stored securely, with counts performed at each shift change. The failure of the nurses to conduct the shift change narcotics count and properly secure the medication led to the loss of the resident's Modafinil, with no resolution as to its whereabouts.
Incomplete and Inaccurate Medical Record Documentation for Medications and Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents reviewed for medication, treatment, and wound administration. Specifically, there were multiple instances where Medication Administration Records (MAR), Treatment Administration Records (TAR), Wound Administration Records (WAR), and Controlled Drug Records were either incomplete, missing, or inaccurately documented. For example, one resident's records for Norco, Pregabalin, tramadol, and wound cleanse treatments were not properly completed or accurately reflected in the MAR, TAR, WAR, and Controlled Drug Records. Another resident's MAR for Lorazepam was missing for two consecutive months, and the documented dose did not match the Controlled Drug Record. A third resident's MAR and Controlled Drug Record for Hydrocodone showed discrepancies in the number of doses administered. Interviews with nursing staff, the DON, and other facility personnel revealed a lack of consistent procedures and understanding regarding documentation requirements. Staff reported that medication errors were not always documented or reported as required, and there was confusion about the retention and submission of narcotic logs, especially for discontinued medications and discharged residents. The DON and other staff acknowledged that documentation practices were not being followed correctly, and some staff expressed concerns about the accuracy and completeness of the records. Additionally, there were reports of medical record entries being removed or edited, further contributing to the lack of reliable documentation. The affected residents had significant medical needs, including pain management for conditions such as cellulitis, end-stage renal disease, morbid obesity, schizoaffective disorder, and dementia. Despite active orders for medications and treatments, the facility's failure to document administration accurately and completely meant there was no reliable record to confirm that residents received their prescribed care. The absence of proper documentation also extended to the facility's narcotic record logs, which were found to be disorganized and inconsistent, with multiple forms in use and missing records for some residents.
Failure to Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs related to their physical, mental, and psychosocial well-being. For one resident with a history of muscle wasting, atrophy, and cognitive communication deficit, the care plan did not address the resident's ongoing refusal to be weighed monthly, despite a physician's order and documentation of refusals in progress notes. The care plan only included general interventions for monitoring signs of malnutrition, without specific strategies for addressing the resident's refusal to be weighed or alternative monitoring methods. Another resident with a history of a left arm fracture, diabetes, malnutrition, and dysphagia had a care plan that failed to address repeated refusals to sit up at a 90-degree angle during meals, as ordered by the physician. Despite documentation of multiple refusals and the resident's report of dizziness when sitting upright, the care plan did not include individualized interventions to address these refusals or alternative approaches to ensure safe feeding and aspiration prevention. Staff interviews and documentation indicated that the resident was not consistently offered the opportunity to sit up for meals, and the care plan was not updated to reflect these ongoing issues. A third resident with dementia, diabetes, sleep apnea, and congestive heart failure used both a CPAP machine and a nebulizer, but the care plan did not address the use, maintenance, or monitoring of these devices. There were no physician orders for the CPAP or nebulizer in the electronic health record, and no documentation of cleaning schedules or replacement parts. Staff and family interviews confirmed the resident's long-term use of these devices and the lack of documentation or care planning related to their use. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents involved.
Failure to Provide Scheduled Showers and Accurate Documentation for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, to three residents who were dependent on staff for personal hygiene. Documentation review revealed that scheduled showers for these residents were not consistently provided according to their care plans and facility protocols. Electronic health records (EHR) and paper shower sheets were either missing, incomplete, or contained inaccurate entries, with staff admitting to documenting tasks in the EHR to avoid system alerts, regardless of whether the care was actually provided. One resident, a female with multiple diagnoses including non-traumatic brain dysfunction, stroke, and partial paralysis, was physically dependent on staff for bathing and required a mechanical lift for transfers. Despite being scheduled for showers three times a week, there was no evidence in the shower binder or EHR that these showers were provided. Both the resident and her family member reported that she did not refuse showers and felt unclean due to missed bathing. Staff interviews confirmed that documentation practices were inconsistent and sometimes inaccurate, with reliance on paper records that were not always completed or retained. Two other residents, both male with significant medical conditions such as dementia, diabetes, and acute kidney failure, also did not receive scheduled showers. One had only a single, undated shower sheet in the binder, and the other had only two completed shower sheets for the review period, with no EHR documentation. Family members reported delays in bathing and related health issues, such as a yeast infection. Staff interviews indicated that short staffing on certain shifts contributed to missed showers, and that documentation was often incomplete or not performed in real time, contrary to facility policy.
Deficient Food Storage, Sanitation, and Temperature Monitoring in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and distribution practices in accordance with professional standards for food service safety in several nourishment room refrigerators. Observations revealed that temperature logs were not maintained or visible on multiple refrigerators, including those in dining rooms and nourishment rooms. Inside the refrigerators, there were visible stains, a human hair, and expired food items such as sour cream packets and half & half cups. Additionally, a multi-use tub of homemade ice cream was found in a freezer without a resident's name or date. One nourishment refrigerator was found to have sugar ants crawling along the freezer door seal. Interviews with facility staff, including the ADON, DON, and ADM, revealed confusion and inconsistency regarding responsibility for maintaining temperature logs, cleaning, and disposing of expired foods. The facility's contract with the contracted kitchen indicated that the kitchen was responsible for stock and cleanliness, while the facility was responsible for temperature monitoring. Pest control invoices confirmed that pest control services had been provided in the months prior to the observations.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments (MDS) within the required 14-day timeframe for two residents. One resident, a male with diagnoses including acute kidney failure, altered mental status, osteoarthritis, low potassium, and hyperosmolality, was admitted but did not have a completed admission MDS assessment within 14 days; the assessment was still in progress and noted as overdue. Another male resident with diagnoses of unspecified dementia, diabetes, sleep apnea, hypertension, atrial fibrillation, congestive heart failure, and GERD also did not have a completed admission MDS assessment within the required timeframe, with the assessment similarly overdue. Interviews with MDS staff revealed that one MDS coordinator had been the only person in the role until recently and had become overwhelmed with new admissions, while the newly hired MDS coordinator was still orienting and attempting to catch up on the workload. The facility did not provide a policy on the timing for completion of MDS assessments when requested. The MDS job description and the Resident Assessment Instrument User's Manual both require that admission MDS assessments be completed within 14 days of admission.
Failure to Assist Resident with Eating Due to Improper Positioning
Penalty
Summary
A deficiency occurred when a female resident with dementia, chronic obstructive pulmonary disease, and anorexia was not provided with the necessary assistance to maintain her ability to perform activities of daily living, specifically eating. The resident's assessment indicated moderate cognitive impairment and a need for setup or clean-up assistance with eating, but no swallowing disorder or weight loss. Her care plan specified that staff assistance was required for eating. During observation, the resident was found in bed with her breakfast tray placed at chin level, unable to see or reach her food, and stated she needed to be repositioned to eat. Interviews with the DON and CNAs revealed uncertainty about who placed the tray and confirmed that the resident was not properly positioned to feed herself. The facility's policy requires that residents receive care and services to maintain their abilities in activities of daily living, including eating, based on their comprehensive assessment. The failure to monitor the resident's assistance needs and ensure proper positioning resulted in the resident being unable to access her meal.
Failure to Ensure Resident Consumed Medications as Ordered
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure that a resident with multiple diagnoses, including non-traumatic brain dysfunction, stroke, seizure disorder, and dysphagia, consumed her nighttime medications as ordered. The resident, who had moderately impaired cognition, was observed to have spit out her medications and stored them in her bedside table after the MA left the room without confirming ingestion. Family members discovered the unconsumed pills and reported that the MA had rushed the resident, not allowing sufficient time for safe medication administration. The MA was also unaware of a standing physician order permitting medications to be crushed and mixed with food or jelly, which could have facilitated safer administration for the resident with swallowing difficulties. Interviews with facility staff revealed that neither the charge nurse nor the DON were aware of the resident's difficulty swallowing medications or the incident of spitting out pills. The MA stated she believed the resident had swallowed the medications and was not aware of the crush order. The facility's medication administration policy requires medications to be administered as ordered, including crushing medications when specified. The failure to ensure the resident consumed her medications as ordered and in accordance with professional standards led to the identified deficiency.
Lack of Physician Orders and Care Plan for Respiratory Devices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required the use of a CPAP machine and a nebulizer. The resident, an elderly male with multiple diagnoses including dementia, diabetes, sleep apnea, congestive heart failure, and atrial fibrillation, was observed using a nebulizer mask and had both a CPAP machine and a nebulizer present in his room. Despite this, there were no physician's orders or care plan interventions documented for the use of either device in the resident's electronic health record (EHR). The care plan only addressed monitoring for labored breathing and use of accessory muscles, and the physician's orders included only PRN albuterol for shortness of breath or wheezing, but not the use of the CPAP or nebulizer machines themselves. Interviews with nursing staff confirmed that the resident used the CPAP nightly and the nebulizer as needed, but acknowledged that no orders for these devices were present in the EHR. Staff relied on their knowledge of the resident's routine rather than documented orders or care plans. Additionally, there was no documentation regarding the replacement of parts or cleaning schedules for either respiratory device. The resident's family member also confirmed the long-term use of the CPAP and nebulizer and noted that the facility was in the process of obtaining a new CPAP machine for the resident.
Failure to Ensure Timely Availability of Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the availability of prescribed medications, specifically Thiamine and Ergocalciferol. The resident, who had diagnoses including sepsis, anxiety, myasthenia gravis, and mild protein calorie malnutrition, was admitted with a care plan that included medication supplements to maintain nutritional status. Record review showed that the resident had active orders for Thiamine and Ergocalciferol, but the Medication Administration Record indicated these medications were not administered because they were on order and not available at the facility. During medication pass, the medication aide prepared the resident's medications except for the unavailable Thiamine and Ergocalciferol, documenting their absence. The aide reported the missing medications to the charge nurse but was unsure why they had not arrived. Interviews with staff revealed inconsistent communication regarding the unavailability of medications, with the charge nurse stating she was not informed and the DON outlining procedures that were not followed. The facility did not provide a policy on medication availability during the survey.
Medication Error Rate Exceeds Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in a medication error rate of 7.69% based on 2 out of 26 observed opportunities. This deficiency involved a resident with multiple diagnoses, including sepsis, anxiety, myasthenia gravis, and mild protein calorie malnutrition, who did not receive ordered doses of Thiamine and Ergocalciferol because the medications were not available for administration. The resident's care plan included medication supplements to maintain adequate nutritional status, and the medication administration record confirmed the missed doses, noting the medications were on order. During medication pass observation, the medication aide prepared all available medications but omitted the unavailable ones, documenting them as on order. The aide reported the missing medications to the charge nurse, but the nurse later stated she was not informed about the unavailability. The facility's policy required staff to administer medications as ordered and to report unavailable medications to nursing leadership, but this process was not followed, resulting in the resident not receiving prescribed medications as scheduled.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication aide (MA) left a medication cart unlocked and unattended in the hallway outside a resident's room. Over-the-counter medications, including Oscal (a calcium supplement) and a Vitamin D supplement, were left out on top of the cart while the MA administered medications inside the room. This allowed the medications and biologicals to be accessible to other staff, residents, or visitors during the period the cart was unattended. The MA acknowledged in an interview that the cart should never be left unlocked or unattended and that medications should not be left out on top of the cart when unattended. The Director of Nursing (DON) confirmed that all staff are expected to keep the medication cart locked unless it is actively being used, and that staff receive regular reminders and annual competency checks regarding medication pass procedures. The facility's policy requires all medications to be stored securely in accordance with professional standards. The failure to lock the medication cart and secure medications was observed and confirmed through staff interviews and policy review.
Failure to Follow Infection Control Protocol During Medication Administration
Penalty
Summary
A medication aide failed to follow proper infection prevention and control procedures during the administration of eye drops to a resident. Specifically, the aide did not perform hand hygiene or don gloves before administering Timolol Maleate Ophthalmic Solution to the resident, nor did she wash her hands after the procedure. This was directly observed by surveyors during a medication pass. The aide later acknowledged in an interview that she should have washed her hands and worn gloves, attributing her lapse to nervousness and recognizing that not doing so could spread germs and infections. The resident involved had a history of sepsis, anxiety, myasthenia gravis, and glaucoma, and was noted to have severely impaired cognition. Facility records and policies reviewed by surveyors confirmed that staff are required to perform hand hygiene and use personal protective equipment before resident care procedures, including medication administration. The Director of Nursing confirmed that all staff had been educated on these requirements and that hand hygiene is part of annual competency checks.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to use appropriate alternatives before installing bed rails for three residents, and did not assess the residents for the risk of entrapment, review the risks and benefits with them or their representatives, or obtain informed consent prior to installation. This deficiency was identified during observations, interviews, and record reviews. The residents involved had various medical conditions, including polyosteoarthritis, chronic heart failure, and cerebral infarction, which could potentially increase their vulnerability to the risks associated with bed rail use. For Resident #1, there was no mention of bed rails in the care plan, no physician orders for their use, and no informed consent or risk assessment on file. An observation revealed that the resident was asleep with side rails in the up position. Similarly, Resident #2's records showed no care plan mention, physician orders, or informed consent for bed rails, and the resident expressed that she did not consent to their use. She also reported a past incident involving the side rails that made her nervous about sleeping in her bed. Resident #3's records also lacked documentation of bed rail use, including care plan mention, physician orders, informed consent, and risk assessment, yet observations showed the resident asleep with side rails up. Interviews with facility staff, including the VPCO, DON, and ADM, revealed that the bed rails were already on the beds when the facility was acquired and were not removed because they were used as enablers. The staff acknowledged the lack of assessments, orders, and consents, and recognized the potential risks of entrapment and injury associated with the use of bed rails without proper documentation and consent. The facility's policy emphasized the need for a person-centered approach, assessment of alternatives, and informed consent, none of which were followed in these cases.
Failure to Notify Residents of Physician Change
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting five residents. This issue arose after the facility terminated the agreement with their Medical Director and changed the attending physician without notifying the residents or their representatives. The change was effective on July 4, 2024, and the lack of communication regarding this change was evident in the interviews and record reviews conducted during the survey. Resident #1, a female with intact cognition, was not informed about the change in her primary physician. She noticed the change when a new doctor visited her, but she was not officially notified. Similarly, Resident #2's responsible party was not informed about the change in the medical director, although they were notified about the facility's change in ownership. Resident #3's responsible party also did not receive any notification about the change in the medical director or the primary physician. The facility's administration acknowledged the oversight in communication. The new administrator and other staff members, including the Director of Operations and the Director of Nursing, admitted that residents and their responsible parties should have been notified 30 days in advance of the change. However, there was no evidence that such notifications were distributed, leading to confusion and a lack of choice for the residents regarding their attending physicians.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure that medications for a resident were stored securely and properly, as required by regulations. During an observation, a medication aide was seen leaving a box of Mucinex tablets and a Baclofen tablet unsecured on top of a medication cart while she went to retrieve an additional Baclofen tablet from the medication room. This lapse in protocol left the medications unattended for approximately 4-5 minutes, although no residents were observed in the hallway during this time. The medication aide acknowledged that leaving medications unattended was against the facility's policy. Additionally, the facility did not properly dispose of medications, as evidenced by a loose Docusate sodium tablet found in a trash can in the private dining room. The Director of Nursing (DON) confirmed that medications should be disposed of in a sharps container and not in the trash. The DON also stated that leaving medications unsecured or improperly disposing of them could lead to serious consequences, such as a resident taking medication that was not theirs. Interviews with staff, including the DON and the Administrator, revealed that the facility's policy required medications to be locked in a medication cart or attended by staff. The facility's Preparation for Medication Administration policy outlined the need for lockable medication carts and proper disposal methods. However, additional policies regarding secure storage and disposal of medications were requested but not provided by the time of the survey exit.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an incident of injury of unknown sources to the state agency within 24 hours, as required by regulations. A male resident, who had been admitted less than 24 hours prior, was found on the floor with a bleeding head wound. The incident was documented by an RN, and the resident was sent to a local hospital for treatment. Despite the severity of the incident, the facility did not report it to the state agency within the mandated timeframe. The administrator was informed of the incident shortly after it occurred, but waited for corporate approval before reporting it to the state, which did not happen until the following day. Interviews with facility staff revealed that the corporate nurse was not made aware of the incident until the day after it occurred, leading to a delay in reporting. The facility's policy mandates that all incidents of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, must be reported to the appropriate agencies within 24 hours. However, this policy was not followed in this case, resulting in a failure to comply with state and federal regulations.
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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