Stone Oak Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 505 Madison Oak Dr, San Antonio, Texas 78258
- CMS Provider Number
- 675968
- Inspections on file
- 44
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Stone Oak Care Center during CMS and state inspections, most recent first.
An LVN completed an initial admission assessment, baseline care plan, and comprehensive care plan for a resident with multiple complex diagnoses without required RN review or oversight. Despite RNs being present in the facility, the necessary RN signature and review were missing, and interviews revealed a lack of understanding among staff regarding the requirement for RN involvement in these processes, resulting in a deficiency related to nursing staff competencies and adherence to scope of practice regulations.
A resident with diabetes did not receive a prescribed dose of Lantus insulin on the first night of admission because an LVN assumed the medication was not available and failed to access the emergency medication kit, despite a physician order and the drug's availability. The LVN also incorrectly documented the administration of the insulin on the MAR, intending only to record blood glucose monitoring.
A resident with diabetes did not receive a prescribed dose of Lantus insulin on their first night in the facility, although an LVN documented that the medication was administered. The LVN later admitted the insulin was not given, mistakenly recording its administration while only intending to document a blood glucose check. The facility did not have a policy addressing documentation accuracy, and the interim DON confirmed the error.
A resident admitted for hospice respite care did not receive prescribed glaucoma eye drops for several days due to a lack of coordination and communication between facility staff and hospice representatives. Although the resident's medication list was available in the electronic record and the medications were brought to the facility, neither the admitting nurse nor the hospice RN reviewed the reconciliation list, resulting in the omission of the medications from initial orders and delayed administration.
A resident with multiple diagnoses, including cancer and muscle wasting, experienced a fall that was documented in risk management and progress notes, with interventions added to the care plan. However, the quarterly MDS assessment was incorrectly coded as having no falls, despite the incident being reported and discussed among staff. The RNAC acknowledged the error, and facility policy requires accurate MDS assessments as the basis for care planning.
The facility did not thoroughly investigate two separate allegations of abuse and neglect, as required by policy. In both cases, the investigations failed to include interviews or assessments of other residents in the same units as the alleged victims, relying instead on interviews from other units and routine staff rounds. Some resident questionnaires were submitted late and lacked identifying information, preventing verification by surveyors.
A resident with dementia and muscle weakness had two PRN Tramadol orders—one for 1 tablet and one for 2 tablets—without clear pain scale parameters to guide administration. Nursing staff were uncertain about when to use each dose, and the orders did not specify indications for administration, leading to inconsistent practices and confusion among staff.
A resident's clinical record contained inaccurate documentation, including notes about conjunctivitis and erythromycin treatment that were not supported by diagnoses, physician orders, or medication administration records. Both the DON and NP confirmed the documentation was entered in error, resulting in incomplete and inaccurate medical records.
A resident with dementia and a forehead wound requiring sutures did not have Enhanced Barrier Precautions (EBP) properly implemented, despite orders and care plans indicating the need. Observations showed no EBP signage or PPE cart, and staff interviews revealed confusion about the resident's EBP status and infection control protocols. Documentation indicated EBP was completed, but actual practices did not align with facility policy.
Three residents had inaccurate MDS assessments, including failure to document hypoglycemic medication use for a diabetic resident, incorrect coding of urinary continence for a resident with a suprapubic catheter, and failure to indicate antidepressant use for a resident with depression. These errors were acknowledged by the MDS coordinator and clinical leadership, and were inconsistent with facility policy and CMS requirements.
Surveyors found expired intravenous antibiotics, a germicidal wipe, and a bottle of Senna-Plus in the medication room and a nursing cart. A resident with multiple diagnoses and severe cognitive impairment had discontinued use of the antibiotics, but the expired medications remained accessible. Staff confirmed the expired items were not used but could not explain their presence, and there was no specific policy for removing expired medications or supplies.
The facility did not obtain food from approved or satisfactory sources and failed to ensure that food was stored, prepared, distributed, and served according to professional standards.
A resident with Alzheimer's disease, heart failure, and other chronic conditions was found to be living in a room where the air conditioning vent was visibly soiled with a black substance, rust, and dust. Facility staff confirmed the vents were dirty, and records showed the room was scheduled for deep cleaning, but the vents had not been cleaned at the time of observation. The resident's care plan identified a risk for infection, and facility policy required a clean environment, which was not maintained.
The facility did not complete or transmit required MDS discharge assessments for two residents after their discharge, despite both having documented discharge plans and care needs. Interviews with the DOCR, DON, and ADM confirmed the assessments were not done, and the responsible staff member was no longer available, resulting in the deficiency.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient measures to prevent UTIs. These deficiencies were observed during the survey and directly impacted residents requiring assistance with bowel and bladder management.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards for individualized resident needs.
A CNA provided peri care to a male resident with severe cognitive impairment and incontinence, changing gloves multiple times without performing hand hygiene between glove changes. This action was observed and confirmed by both the CNA and the DON, and was not in accordance with the facility's hand hygiene policy.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised for several hours after staff failed to apply a wander guard and did not communicate her supervision needs. The resident exited the building when an RN, unaware of her status, opened the door for her. The incident revealed lapses in staff communication, assessment, and adherence to elopement prevention protocols.
Staff failed to immediately report an incident in which a visitor was observed pounding on a resident's bed and yelling, as required by policy and regulation. The incident was reported up the internal chain of command but not to the administrator or state agency within the required timeframe, and the administrator only learned of the event after surveyor intervention. The resident involved had severe cognitive impairment and was highly dependent on staff for care.
A resident with severe cognitive impairment was subjected to alleged verbal abuse and physical intimidation by a visitor, as documented in progress notes. The facility did not investigate or report the incident as required, due to the administrator's lack of awareness of the documented allegation.
The facility did not maintain complete and accurate medical records for two residents, including a missing and incomplete discharge summary for one resident and inconsistent documentation of bathing for another. Staff interviews confirmed that required documentation was either not completed or updated after the fact, contrary to professional standards.
A resident was inaccurately documented as having a feeding tube in their MDS assessment, despite observations and interviews confirming they were eating by mouth. The error was acknowledged by the MDS Coordinator, who stated it was an accidental entry, potentially risking inadequate care.
The facility failed to maintain accurate care plans for two residents, leading to potential care discrepancies. One resident's care plan did not reflect their daily anticonvulsant medication, while another's inaccurately included oxygen therapy. These inaccuracies were confirmed through interviews and record reviews, posing risks of inappropriate or missed care.
A resident with a gastrostomy tube did not receive the prescribed enteral feeding rate, and medication flushes were not administered as ordered. The feeding pump was set at 60cc per hour instead of the prescribed 65cc per hour, and an LVN failed to perform necessary water flushes before and between medications. The DON confirmed the importance of adhering to these protocols to prevent malnutrition and tube blockage.
A resident with moderate cognitive impairment and multiple diagnoses was prescribed continuous oxygen at 2L/min but was observed receiving 3L/min. An agency nurse did not verify the oxygen setting, assuming it was correct. The DON acknowledged the risk of respiratory distress if the prescribed rate is not maintained, and the facility lacked a policy for oxygen therapy management.
A nurse failed to perform required water flushes before and between medication administrations via G-tube for a resident with dysphagia and gastrostomy status. Despite having passed a competency checklist, the nurse did not adhere to the prescribed procedure, as confirmed by another nurse and the DON. This failure was observed during medication preparation and contradicted the facility's policy on enteral tube medication administration.
A CNA in an LTC facility was observed picking up a roll that fell from a resident's tray with her bare hands and placing it back on the plate, contrary to the facility's food safety policy. The CNA acknowledged the unsanitary action but did not immediately replace the roll. The DON confirmed that staff are trained to avoid direct hand contact with food to prevent contamination.
Two residents were affected by infection control lapses in a facility. A CNA failed to change gloves and sanitize hands during incontinent care, while an LVN did not wear gloves when handling medication for a resident with a gastrostomy tube. Both staff members had received infection control training, but did not adhere to protocols, as confirmed by the DON.
Failure to Ensure RN Oversight of LVN Admission Assessments and Care Planning
Penalty
Summary
The facility failed to ensure that nursing staff, specifically an LVN, had and demonstrated the appropriate competencies and skill sets to provide nursing and related services in accordance with regulatory requirements. An LVN conducted an initial admission assessment, initiated a baseline care plan, and started the comprehensive care plan for a newly admitted resident with complex medical diagnoses, including acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, and bilateral primary open-angle glaucoma. The LVN completed a head-to-toe assessment and care planning without the required review or oversight by an RN, as indicated by the absence of an RN signature on the assessment documentation. Interviews revealed that the LVN believed she was permitted to complete both the initial and baseline assessments and care plans independently, based on her training and facility practice, and was unaware that RN review was required. The Director of Nursing Services (DNS) and the new DON both confirmed that facility practice involved LVNs completing these assessments, with the expectation that an RN would review and sign off within 48-72 hours. However, in this instance, the RN review did not occur as required, and the baseline care plan and initial assessment were not signed by an RN. Record review and interviews further established that the facility had RNs on staff during the time of the admission, but the process for ensuring RN oversight was not followed. The Texas Board of Nursing LVN Scope of Practice specifies that LVNs must work under the supervision of an RN and are not permitted to perform independent comprehensive assessments or initiate care plans without RN involvement. The failure to ensure RN review and oversight of the LVN's assessments and care planning resulted in a deficiency related to nursing staff competencies and scope of practice.
Failure to Administer Ordered Insulin Due to Medication Access and Documentation Errors
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for a resident with multiple diagnoses, including type 2 diabetes mellitus. Upon admission, the resident had a physician's order for Lantus (insulin glargine) to be administered subcutaneously at bedtime. Although the medication was documented as given on the Medication Administration Record (MAR), the assigned LVN did not actually administer the insulin on the first night of admission. The LVN stated she assumed the medication had not arrived from the pharmacy and inadvertently documented its administration when she only intended to record the completion of blood glucose monitoring (accuchecks). The resident later reported not receiving her insulin on the first night but had no noticeable effects and continued to receive her medication on subsequent nights. The facility's Director of Nursing Services confirmed that Lantus was available in the emergency medication kit and should have been administered as ordered. The LVN did not access the e-kit to obtain the medication, despite its availability and the presence of a physician order. Facility policy required medications to be administered accurately and timely as ordered by the physician.
Inaccurate Documentation of Insulin Administration by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) documented in the medical record that she administered Lantus (insulin glargine) to a newly admitted resident with type 2 diabetes, when in fact the medication was not given. The resident's medical record, including the Medication Administration Record (MAR), indicated that the insulin was administered as ordered by the physician. However, during interviews, the LVN admitted she did not administer the insulin because she assumed it had not yet arrived from the pharmacy, and she inadvertently documented its administration while intending only to record the completion of blood glucose monitoring (accuchecks). The LVN also acknowledged that the insulin was available in the facility's emergency medication kit but did not access it or administer the medication. The resident, who had recently been admitted with diagnoses including acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, and primary open-angle glaucoma, reported not receiving her insulin on her first night in the facility but had no adverse effects and had informed staff. The facility lacked a specific policy addressing documentation accuracy, and the existing medication administration policy did not cover documentation procedures. The interim Director of Nursing Services (DNS) confirmed the documentation error and emphasized the importance of accurate record-keeping and following physician orders.
Failure to Coordinate Hospice Medication Orders on Admission
Penalty
Summary
The facility failed to effectively collaborate and communicate with hospice representatives to ensure a resident received prescribed glaucoma medications upon admission. The resident, admitted for hospice respite care, had a documented history of primary open-angle glaucoma and was taking three specific eye drop medications at home, as detailed in her preadmission home health paperwork. Despite this information being uploaded into the facility's medical record prior to admission, the medications were not included in the initial hospice orders written at the facility, and the resident did not receive these medications for several days after admission. Interviews revealed that the admitting nurse did not review the medication reconciliation list available in the resident's electronic medical record, relying instead on verbal instructions from the Admissions Coordinator and the hospice nurse. The hospice nurse, in turn, based her medication orders on the medications physically provided by the resident and did not consult the preadmission medication list. The resident and her family reported that the eye drops were brought to the facility and given to staff, but the medications were not administered until several days later, after the issue was discovered by facility leadership. Facility leadership, including the DON and DNS, stated that their process was to follow the orders written by the hospice nurse and not to reference the preadmission medication reconciliation list unless questions arose. The contract between the facility and hospice required joint development and agreement on the plan of care, but in practice, the facility deferred to hospice for medication orders. This lack of coordination and communication resulted in the resident missing several doses of her prescribed glaucoma medications immediately following admission.
Inaccurate MDS Coding of Resident Fall
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status regarding falls. Specifically, a male resident on hospice care with diagnoses including malignant neoplasm of the kidney, muscle wasting, and anxiety experienced a fall in his room while reaching for a blanket. The incident was documented in the facility's risk management system and in progress notes, with no injuries observed and appropriate notifications made to the physician, DON, and responsible party. Interventions, such as adding bed bolsters, were implemented and documented in the care plan. Despite the fall being documented in multiple records and discussed among staff, the resident's subsequent quarterly MDS assessment was coded as having had no falls since the prior assessment. The RNAC responsible for completing the MDS stated that her process for identifying falls included attending interdisciplinary meetings and reviewing risk management reports. However, she acknowledged that she coded the MDS incorrectly, indicating no falls, despite the existence of a risk management report documenting the incident. Interviews with the RNAC, DON, and administrator revealed a belief that the miscoding on the MDS would not impact the resident's care as long as the care plan was accurate and interventions were in place. The facility's policy requires that each resident receives an accurate assessment and that the MDS serves as the clinical basis for care planning and delivery. In this case, the MDS assessment did not accurately reflect the resident's fall history, constituting a deficiency in assessment accuracy.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for two residents reviewed for abuse and neglect. In the first case, a family member alleged neglect after observing a resident in a soiled brief. The facility's investigation did not include a physical assessment of the resident due to her discharge status and only included resident and staff interviews from other units, not the unit where the resident resided. The administrator confirmed that residents on the relevant unit were not surveyed during the investigation, and the determination of safety was based on routine staff rounds rather than direct investigation of the specific unit involved. In the second case, a family member alleged that a resident had been physically assaulted, resulting in a facial injury. The investigation included a physical assessment of the resident, interviews with the resident and family, and review of video footage. However, the investigation did not include abuse or neglect surveys of residents in the memory care unit where the resident lived, as the administrator believed those residents could not participate due to cognitive decline. No physical assessments were performed in place of verbal surveys for these residents, and the administrator relied on staff interviews and routine rounds to determine safety. Facility policy required investigations to include observations of the alleged victim, monitoring of at-risk residents, and assessment of interactions between staff and residents. Despite this, the investigations for both residents did not include direct interviews or assessments of other residents in the same units as the alleged victims. Additionally, some resident interview questionnaires were provided after the survey exit, without documentation of room numbers, making it impossible for surveyors to verify their relevance to the cases.
Lack of Clear Parameters for PRN Pain Medication Orders
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident with dementia and muscle weakness. Specifically, the resident had two PRN orders for Tramadol 50mg—one for 1 tablet and one for 2 tablets every 6 hours as needed for pain—without clear parameters or indications for when each dose should be administered. The medication administration record showed that the 1-tablet dose was given multiple times for varying pain levels, but the 2-tablet dose was never administered. Nursing staff reported uncertainty about when to use each order, and the orders lacked specific pain scale parameters to guide administration. The facility's pain management policy required monitoring and following physician orders, but the orders themselves were not sufficiently detailed to ensure proper administration. Interviews with staff revealed that nurses were unsure about the correct circumstances for administering the different PRN doses, and the pharmacist acknowledged that including pain scale parameters would be best practice. The physician clarified that the orders should have specified 1 tablet for pain levels 1-4 and 2 tablets for pain levels 5-10, but this was not reflected in the orders as written or transcribed. The lack of clear parameters in the PRN orders led to inconsistent administration practices and potential confusion among staff.
Inaccurate Clinical Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident, as required by accepted professional health information management standards. Specifically, the resident's clinical record included provider notes documenting symptoms of eye redness, a diagnosis of conjunctivitis, and treatment with erythromycin ointment. However, a review of the resident's list of medical diagnoses did not include conjunctivitis, and there were no corresponding physician orders or medication administration records indicating that erythromycin was ever ordered or administered. During interviews, both the Director of Nursing (DON) and the Nurse Practitioner (NP) stated they did not recall the resident experiencing eye redness, and the NP confirmed that the documentation regarding conjunctivitis was entered in error. The facility's policy requires that a medical record be maintained for every person admitted, in accordance with accepted professional standards and practices. The inaccurate documentation in the resident's clinical record represents a failure to meet these standards.
Failure to Implement Enhanced Barrier Precautions for Resident with Wound
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with dementia and muscle weakness who had a forehead wound with sutures. Despite physician orders and care plans indicating the need for Enhanced Barrier Precautions (EBP) every shift, there was no signage or PPE cart present outside the resident's room on multiple observations. The resident's Treatment Administration Record (TAR) was signed as if EBP had been implemented, but staff interviews revealed confusion and lack of awareness regarding the resident's EBP status. The CNA was unaware of any isolation precautions for the resident, and the LVN did not recall signing the TAR or understand why EBP was ordered. The Director of Nursing (DON), acting as interim infection preventionist, also expressed uncertainty about the necessity of EBP for the resident and was unsure why the order was present or why staff had documented its implementation. The facility's infection control policy required EBP for residents with open wounds requiring a dressing, but the resident's wound was observed without a dressing. The lack of proper implementation and documentation of EBP, as well as staff confusion regarding infection control protocols, led to the deficiency.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the clinical status of three residents. For one resident with diabetes mellitus, the admission MDS did not indicate the use of hypoglycemic medication, despite active orders and administration of insulin (Lantus) for diabetes management. Both the Director of Clinical Records (DOCR) and the Director of Nursing (DON) acknowledged that the omission was an error and that the MDS should have accurately documented the use of insulin as a high-risk medication. Another resident with a flaccid neuropathic bladder and a suprapubic catheter had their Quarterly MDS assessment incorrectly coded. Although the resident had an indwelling catheter, the assessment was marked as "Always incontinent" instead of "Not rated" as required by the CMS RAI Manual for residents with catheters during the look-back period. The MDS coordinator and DOCR confirmed the miscoding, and the DON stated that MDS accuracy was the responsibility of the MDS coordinator. A third resident, diagnosed with depression and prescribed mirtazapine, had their quarterly MDS assessment coded as not receiving antidepressants, despite physician orders and medication administration records confirming ongoing antidepressant therapy. The MDS coordinator acknowledged the error, stating the resident should have been coded as receiving an antidepressant. Facility policy and CMS regulations require accurate and comprehensive assessments to ensure proper care planning and service delivery.
Expired Medications and Supplies Not Removed from Medication Room and Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the timely removal of expired medications and supplies from the medication room and nursing carts. During observations, three expired intravenous antibiotic solutions intended for a resident with a history of sepsis, muscle weakness, type 2 diabetes, urinary tract infection, and hypertension were found in the medication room after the medication had been discontinued. Additionally, an expired germicidal wipe and an expired bottle of Senna-Plus were found in the medication room and a nursing cart, respectively. Staff interviews confirmed that these expired items were not in use, but there was no clear explanation for why they remained accessible. Record reviews indicated that the resident had severe cognitive impairment and had received the antibiotic as ordered, with the medication discontinued prior to the survey. The Director of Nursing and nursing staff acknowledged that expired medications and supplies should have been removed but were not, and also noted the absence of a specific facility policy regarding the handling of expired medications and wipes. The facility's existing medication administration policy did not address the removal of expired items.
Noncompliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating noncompliance with established food safety and handling protocols. No additional details regarding specific residents, staff, or events are provided in the report.
Soiled Air Conditioning Vents in Resident Room
Penalty
Summary
A deficiency was identified when a resident's room was found to have an air conditioning vent in the ceiling that was visibly soiled with a black substance and rust, and the return vent was covered with dust. This was observed during a facility survey, and both the Director of Nursing (DON) and the District Manager for environment confirmed the presence of dust, rust, and dirt on the vent. The facility's deep clean schedule indicated that the room was scheduled for cleaning, but at the time of observation, the vents remained unclean. The resident involved was an elderly male with a history of Alzheimer's disease, heart failure, muscle weakness, muscle wasting and atrophy, and dementia. His quarterly MDS assessment indicated a BIMS score of 00, showing he was unable to complete the interview. The resident's care plan noted a risk for infection due to his compromised medical condition. The facility's policy required the environment to be maintained to protect the health and safety of residents, personnel, and the public, but the observed condition of the air conditioning vents did not meet these standards.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to encode and transmit required Minimum Data Set (MDS) discharge assessments within 14 days after discharge for two residents. For one resident, who had diagnoses including congestive heart failure, peripheral vascular disease, and acute respiratory failure with hypoxia, there was no discharge MDS assessment completed or transmitted as of several months after discharge. This resident's care plan included discharge planning interventions, and records indicated he was to be discharged home with family and provider services. For the second resident, who had diagnoses of muscle weakness, depression, and hypertension, and was cognitively intact, there was also no discharge MDS assessment completed or transmitted after discharge to a private home or apartment. This resident's care plan included a focus on returning home with supportive care and services. Interviews with facility staff, including the Director of Clinical Reimbursement (DOCR), Director of Nursing (DON), and Administrator (ADM), confirmed that the discharge MDS assessments were not completed for these two residents. The DOCR acknowledged the missing assessments and was unsure why they were not completed, noting that the responsible staff member was no longer available. The DON and ADM were unaware of the missing assessments until the time of the interview and recognized that the assessments had not been completed or submitted as required.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and were directly related to the care provided to residents requiring assistance with bowel and bladder management.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Perform Hand Hygiene Between Glove Changes During Peri Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection control procedures while providing peri care to a male resident with severe cognitive impairment, hemiplegia, and incontinence. During the care, the CNA changed gloves multiple times without sanitizing or washing hands between glove changes, despite the facility's policy requiring hand hygiene between glove changes. This was observed while the CNA cleaned the resident's groin, buttock, and rectal areas and replaced the resident's brief. Interviews with the CNA and the Director of Nursing (DON) confirmed that hand hygiene should have been performed before donning new gloves to prevent infection. The facility's hand hygiene policy, revised in January 2023, specifically required the use of alcohol-based hand rub or soap and water between glove changes. The failure to adhere to this policy was directly observed and acknowledged by both the CNA and the DON.
Resident Elopement Due to Failure in Supervision and Safety Protocols
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, including vascular dementia and Alzheimer's disease, was able to elope from the facility without staff knowledge for nearly seven hours. The resident had a history of wandering, as indicated by her previous facility and her Minimum Data Set (MDS) assessment, which showed a BIMS score of 1 out of 15 and recent wandering behavior. Despite this, the resident was not provided with a wander guard upon admission, and staff failed to implement appropriate supervision or monitoring measures. The sequence of events leading to the deficiency began with the resident's admission, during which the need for a wander guard was communicated to staff and documented in the electronic medical record (EMR) dashboard. However, the assigned nurse did not apply the wander guard, and there was a lack of communication between staff regarding the resident's supervision needs. Video surveillance showed that the wander guard was handled but not applied, and the nurse going on break did not relay any special supervision instructions. Later, a registered nurse opened the facility door and allowed the resident to exit, not recognizing her as a resident. The resident was able to leave the facility and was later found at a nearby hospital, which contacted the facility. Staff interviews revealed gaps in training and procedures for identifying residents versus visitors, as well as failures in following established protocols for new admissions at risk for elopement. The facility's policy required assessment and intervention for elopement risk, but these were not properly executed, resulting in the resident's unsupervised exit.
Failure to Timely Report Alleged Abuse by Visitor
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, a visitor was observed by a CNA pounding hard on a resident's bed and yelling, "Wake up!" The resident's roommate questioned the visitor's behavior, asking why they were always so mean. The CNA reported the incident to an LVN, who then reported it to the ADON, but neither the administrator nor the state agency was notified within the required timeframe. The administrator only became aware of the incident after being informed by the surveyor and confirmed that she had not seen the relevant nursing note prior to this intervention. The resident involved was an elderly female with Alzheimer's disease, severe cognitive impairment (BIMS score of 01), and significant functional dependencies, making her particularly vulnerable. Record review confirmed that no self-reported incidents regarding allegations of neglect or abuse were submitted to the state system. Interviews with staff revealed a misunderstanding of the reporting chain of command, with both the CNA and LVN believing that their actions fulfilled reporting requirements, while the ADON did not recall receiving a report. Facility policy required prompt reporting of suspected abuse, including by visitors, but this was not followed in this case.
Failure to Investigate and Document Alleged Abuse by Visitor
Penalty
Summary
The facility failed to provide evidence that all allegations of abuse, neglect, or mistreatment were thoroughly investigated and documented for one resident. Specifically, a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and anxiety, was the subject of an incident in which a visitor was observed angrily pounding on her bed and yelling at her to wake up. The resident was also heard asking the visitor why they were always so mean to her. This incident was documented in the resident's progress notes. Despite the documentation of this event, the facility administrator confirmed that no investigation was conducted because she was unaware of the incident and had not reviewed the progress note prior to the surveyor's inquiry. The facility's policy requires prompt reporting and investigation of all suspected abuse, including verbal abuse by visitors, and mandates reporting to the appropriate authorities within specified time frames. However, in this case, the required investigation and reporting did not occur.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. For one resident, the electronic medical record did not contain a completed discharge summary at the time of discharge. The discharge summary was found to have errors and was not marked as complete or locked in the system, with missing answers to required prompts. Interviews with staff confirmed that the summary was not finalized according to facility expectations, which require a completed, signed, and dated document without errors. For another resident, documentation of showers or baths was inconsistent and not appropriately recorded in the electronic medical record. Initially, only one shower was documented for a specific week, but later, an additional entry was added after staff were prompted to update their documentation. The CNA responsible stated that the shower had been provided but was not documented at the time, and the entry was made later to keep records up to date. The facility's policy requires that a medical record be maintained for every resident in accordance with accepted professional standards, including accurate records of care and services provided.
Inaccurate MDS Assessment for Resident Without Feeding Tube
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, identified as Resident #55, who was incorrectly documented as having a feeding tube. This error was discovered during a review of the resident's quarterly MDS assessment dated May 1, 2024, which inaccurately indicated the presence of a feeding tube. However, observations and interviews confirmed that Resident #55 was eating meals by mouth and did not have a feeding tube. The resident's care plan, dated June 5, 2024, also did not identify the presence of a feeding tube. Interviews with the Assistant Director of Nursing (ADON) and the MDS Coordinator further confirmed that Resident #55 did not have a feeding tube. The ADON stated that the resident had been eating meals and snacks by mouth and had never had a feeding tube during the ADON's tenure at the facility. The MDS Coordinator acknowledged that the feeding tube was checked accidentally during the last assessment and recognized the risk of the resident not receiving appropriate care due to this error. The facility's failure to accurately assess the resident's status could potentially lead to inadequate care.
Inaccurate Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which led to deficiencies in their care. For one resident, the care plan did not reflect the daily administration of an anticonvulsant medication, Keppra, which was prescribed for seizure management. Despite the resident's medical records and medication administration records indicating the use of Keppra, the care plan was not updated to include this critical information. Interviews with the resident and facility staff confirmed the oversight, highlighting the risk of missing important care information due to inaccuracies in the care plan. For another resident, the care plan inaccurately included oxygen therapy as part of the resident's care, despite the absence of any physician orders or observations of the resident receiving such therapy. The resident confirmed not being on oxygen therapy recently, and staff interviews corroborated that the care plan should not have included this treatment. The inaccuracies in the care plans could lead to residents receiving inappropriate or missed care, as the care plans serve as essential communication tools for staff to understand and provide the necessary care.
Deficiency in Enteral Feeding and Medication Administration
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube received the appropriate treatment and services as ordered by the physician. Specifically, the enteral feeding tube rate for the resident was set at 60cc per hour instead of the prescribed 65cc per hour. This discrepancy was observed during a survey, and the responsible nurse admitted to not checking the feeding pump's settings, assuming it was correct. The Director of Nursing (DON) confirmed the importance of maintaining the prescribed feeding rate to prevent malnutrition and ensure the resident receives the necessary nutrients. Additionally, the facility did not adhere to the prescribed medication administration protocol for the resident with the gastrostomy tube. An LVN failed to administer the required water flushes before and between medications, as confirmed by another LVN present during the administration. The DON acknowledged the necessity of these flushes to prevent clogging or blockage of the tubing. The facility lacked a specific policy or procedure on G-tube management, which was confirmed by the Administrator when requested by the surveyor.
Failure to Provide Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as observed by surveyors. Resident #16, who was moderately cognitively impaired and had diagnoses including cerebral atherosclerosis, refractory anemia, and unspecified convulsions, was prescribed continuous oxygen at 2 liters per minute. However, during multiple observations on the same day, the resident's oxygen concentrator was found to be set at 3 liters per minute, contrary to the prescribed rate. An interview with RN A, an agency nurse assigned to the resident, revealed that she did not verify the oxygen concentrator's setting and assumed it was correct. The Director of Nursing confirmed the importance of maintaining the prescribed oxygen rate to prevent respiratory distress. Additionally, the facility lacked a policy or procedure for oxygen therapy management, as confirmed by the Administrator when requested by the surveyor.
Failure in G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure that a nurse, identified as LVN C, demonstrated competency in administering medications via a G-tube for a resident with dysphagia, atherosclerotic heart disease, and gastrostomy status. The resident, who was moderately cognitively impaired and dependent on staff for activities of daily living, had active orders requiring specific water flushes before and between medication administrations through the G-tube. However, during an observation, LVN C did not perform the required premedication water flush of 30 CC and did not flush with water between medications, as confirmed by another nurse, LVN D, who was present during the administration. Interviews with LVN C and the Director of Nursing (DON) confirmed the necessity of the flushes to prevent clogging or blockage of the tubing. Despite LVN C having passed a competency checklist for tubing and medication administration just two days prior, the failure to adhere to the prescribed procedure was evident. The facility's policy on medication administration via enteral tube also outlined the importance of flushing to maintain tube patency, which was not followed in this instance.
Food Safety Protocol Breach
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a dining session. A Certified Nursing Assistant (CNA) was seen picking up a roll that had fallen from a resident's tray onto the table with her bare hands and placing it back onto the resident's plate. This action was contrary to the facility's policy, which prohibits direct contact with food using bare hands. The CNA acknowledged that she should have replaced the roll instead of handling it with her hands, recognizing the unsanitary nature of her action. Despite this acknowledgment, the resident continued to eat the roll before the CNA returned with a replacement. The Director of Nursing (DON) confirmed that staff are trained not to touch residents' food with bare hands to prevent contamination and potential illness. The facility's policy on food preparation and handling, revised in June 2019, explicitly states that bare hands should not come into direct contact with food. This incident highlights a lapse in following established food safety protocols, which could affect residents dining in the facility's dining room.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving improper care practices. In the first incident, a Certified Nursing Assistant (CNA) did not change gloves or sanitize her hands before touching a clean brief after providing incontinent care to a resident. This resident had multiple diagnoses, including anemia, hypertension, and chronic kidney disease, and required extensive assistance with daily activities. The CNA confirmed during an interview that she did not follow proper hand hygiene protocols, despite having received training in infection control. In the second incident, a Licensed Vocational Nurse (LVN) failed to wear gloves while handling medication for a resident who received nutrition and medication via a gastrostomy tube. The resident had a history of dysphagia and atherosclerotic heart disease and was dependent on staff for assistance with activities of daily living. The LVN acknowledged the lapse in protocol during an interview, confirming that she should have worn gloves to prevent cross-contamination. The Director of Nursing (DON) confirmed that both staff members had received infection control training within the year, and the facility's policies required sanitary practices during medication administration.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
