Terra Bella Health And Wellness Suites
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 12262 Cityscape Ave, Houston, Texas 77047
- CMS Provider Number
- 676450
- Inspections on file
- 46
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 17 (3 serious)
Citation history
Health deficiencies cited at Terra Bella Health And Wellness Suites during CMS and state inspections, most recent first.
A resident with dementia, severely impaired cognition, limited range of motion, and bowel and bladder incontinence received incontinent care during which a CNA was repeatedly observed on video throwing used disposable pads onto the floor instead of properly disposing of them. The facility’s Infection Preventionist stated that soiled or wet pads should be placed in a clear plastic bag and sent to the laundry or utility closet, and that placing them on the floor was an infection control issue, particularly when contaminated with urine or feces. These actions conflicted with the facility’s linen and laundry policy requiring sanitary handling of soiled linen and adherence to universal/standard precautions.
A newly hired CNA on her first orientation day was allowed to assist a resident with dementia, muscle wasting, and dysphagia with eating without supervision, despite the resident’s care plan requiring substantial/maximal assistance and specific positioning to reduce choking and aspiration risk. The CNA provided hands-on feeding for a period reported to be up to 45 minutes alone, contrary to the ADON’s description that first-day orientation should be shadowing only and the facility’s CNA orientation policy requiring instruction on skill weaknesses before performing tasks.
A resident with a left foot wound and heel infection was assisted with a shower before a wound care appointment, during which the wound dressing became wet despite physician's orders to keep it dry. The resident was sent to the appointment with the wet dressing, and staff interviews confirmed the dressing should have been changed if wet, indicating a failure to follow professional standards and the care plan.
A resident with severe cognitive impairment and limited mobility was transferred using a mechanical lift by only one staff member, contrary to standard practice requiring two staff. The resident was suspended and swinging in the air during the transfer, which was observed on video and confirmed by the DON. The facility's policy did not specify the required number of staff for such transfers.
A nurse failed to follow physician orders and facility policy by administering multiple enteral medications as a single mixture instead of separately with warm water flushes for a resident with a gastrostomy tube. This action was inconsistent with the resident's care plan and established nursing protocols, as confirmed by staff interviews and record review.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
The facility did not ensure that each resident received an accurate assessment, resulting in incomplete or incorrect evaluations necessary for determining appropriate care and services.
A medication cart containing OTC and prescription medications, syringes, lancets, and pen needles was found unlocked and unattended in a hallway. An LVN left the cart unsupervised after being interrupted during medication pass, contrary to facility policy requiring carts to be locked when not in use. The Interim DON confirmed that this practice was not in accordance with established procedures to prevent unauthorized access.
A resident with dysphagia and severe cognitive impairment was served a mechanical soft meal instead of the physician-ordered pureed diet. The dietary aide misread the meal ticket and placed the wrong food on the tray, which was then delivered and partially fed to the resident by a CNA before the error was discovered by a nurse. The incident involved failures by both dietary and nursing staff to verify the correct diet consistency before serving and feeding.
A resident developed a stage 3 sacral pressure ulcer and an unstageable pressure injury due to the facility's failure to provide adequate pressure ulcer care and prevention. Despite the resident's risk factors, staff did not follow protocols for skin assessments and wound interventions, leading to a delay in care. Communication breakdowns and lack of documentation contributed to the oversight, placing the resident at risk of pain and infection.
A resident with multiple medical conditions, including dementia and functional quadriplegia, was found with a thick accumulation of a brown, flaky substance on her scalp and matted hair that required cutting. The facility failed to document or address these grooming deficiencies, and there was no communication with the resident's responsible party or physician. The lack of proper care placed the resident at risk for scalp issues and infection.
A wound care nurse announced from the hallway that she was about to perform wound care on a resident's sacrum, with the door half-open and within hearing range of others. The resident, who is cognitively intact and fully dependent due to quadriplegia and other conditions, was not aware of the announcement but stated he would not want others to know about his care. The facility's policy requires auditory privacy during treatment, and the administrator confirmed this was a dignity concern.
A resident with a stage 4 pressure ulcer received wound care from a nurse who failed to change gloves between cleansing the wound and applying the new dressing, and did not allow hand sanitizer to dry before donning gloves. The nurse admitted to not following facility policy, and the facility's wound care checklist required glove changes and proper hand hygiene, which were not followed during the procedure.
The facility's kitchen failed to store and label a 13.7-quart container of brown sugar according to professional standards, leaving it open to potential contamination. Staff interviews confirmed the risk of contamination and illness due to the unlabeled and unsealed container, which violated the facility's Nutrition Policies and Procedures.
A facility failed to coordinate PASRR assessments for a resident with mental illness, not identifying her condition in the PASRR Level 1 Screening. The resident had diagnoses of metabolic encephalopathy, depression, and anxiety disorder, and was on antidepressant medications. The MDS Coordinator acknowledged the oversight, noting the process involved verifying diagnoses and filling out form 1012 for discrepancies. The Corporate MDS Nurse confirmed the facility's responsibility in ensuring accurate PASRR screenings and necessary psych services.
The facility failed to secure the lid of one of its dumpsters, as observed during a survey. This non-compliance with the facility's waste disposal policies could attract pests, posing a potential safety issue for residents. Interviews with the Cook and Dietary Manager confirmed awareness of the requirement to keep dumpster lids closed.
A facility failed to ensure a resident with a G-tube received appropriate care, as RN A did not verify tube placement by aspirating stomach contents before administering water flushes and medications. Instead of using gravity, RN A used a syringe plunger, contrary to standards of practice. The resident, with a history of neurological conditions and dysphagia, was at risk due to these actions, which were confirmed by the DON.
A resident with COPD did not receive proper respiratory care as their oxygen tubing was not labeled or dated, and the humidifier was improperly connected. Staff interviews revealed non-compliance with the facility's oxygen therapy policy, risking infection and respiratory distress.
The facility failed to accurately assess and document behaviors for two residents on their MDS assessments. One resident, with multiple diagnoses including schizophrenia, refused care multiple times, yet her MDS showed no behavioral symptoms. Another resident with dementia and anxiety also refused care, but her MDS inaccurately reflected no behaviors. Staff interviews revealed oversight in coding these behaviors, potentially risking inadequate care for the residents.
A resident with multiple medical conditions and cognitive impairment did not receive adequate assistance with ADLs, leading to poor personal hygiene. Observations showed long, dirty fingernails and matted hair, while staff interviews revealed inconsistencies in care and communication. The DON acknowledged the need for nail trimming and hair care, but the responsibility was not clearly assigned, resulting in the deficiency.
A facility failed to provide appropriate care for a resident with a hand contracture, neglecting to implement necessary interventions. The resident, with multiple health issues and severe cognitive impairment, was observed with a contracted hand lacking a hand roll, and poor hygiene. Staff interviews revealed a lack of awareness and action regarding the resident's needs, and the care plan did not address the contracture. The facility's policies on joint mobility were not followed, leading to a significant oversight in care management.
A resident with severe cognitive impairment was found in an unsanitary condition, with urine-soaked items left on her wheelchair, leading to a strong ammonia smell in her room. The incident involved a new aide who forgot to remove the soiled linen, and the family member had difficulty addressing the issue with the weekend supervisor. The facility's grievance system recorded the incident, but no immediate corrective actions were noted.
The facility failed to provide necessary treatment and services for residents with pressure ulcers, leading to inadequate care for two residents. The facility did not follow physician orders, lacked essential supplies, and staff did not perform proper hand hygiene, increasing the risk of infection and worsening of pressure ulcers.
The facility failed to provide proper incontinence and catheter care, leading to increased risk of urinary tract infections. A CNA did not follow proper technique during incontinence care, and an ADON placed a catheter bag on the bed during wound care. Additionally, a resident's catheter strap was missing for a week, increasing the risk of urethral trauma and infection.
The facility failed to maintain an infection prevention and control program, leading to deficiencies in the care of two residents and the actions of two staff members. An ADON did not perform proper hand hygiene during wound care, and a CNA failed to change gloves and wash hands during incontinence care, risking cross-contamination and infections.
A resident with multiple medical conditions did not receive prescribed wound care medications due to a lapse in updating the electronic medical record and failure to follow physician orders. The ADON also did not maintain proper hand hygiene during the wound care procedure.
Improper Handling of Soiled Incontinent Pads During Resident Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the handling of soiled incontinent pads for one resident. The resident was an older adult with dementia, severely impaired cognition, limited functional range of motion in both arms and legs, and was care planned as incontinent of bowel and bladder. Video review on three separate dates showed the same unidentified CNA providing incontinent care at the resident’s bedside and, during each episode, throwing a used disposable pad onto the floor instead of handling it according to infection control practices. The videos documented that during incontinent care, the CNA repeatedly discarded wet and/or soiled pads by throwing them onto the floor beside or behind her. The facility’s Infection Preventionist stated that soiled or wet pads should be placed in a clear plastic bag and sent to the laundry or utility closet, and that placing such items on the floor constituted an infection control issue, especially if contaminated with urine or feces. The facility’s written policy on Linen and Laundry Procedures required sanitary processing and storage of soiled linen and the use of universal/standard precautions by all personnel handling soiled linen. The observed staff actions were inconsistent with these stated procedures and expectations.
Unsupervised New CNA Assisted High-Risk Resident With Eating Without Demonstrated Competency
Penalty
Summary
The facility failed to ensure that a nurse aide demonstrated competency in skills and techniques necessary to meet a resident’s assessed needs and care plan requirements for safe eating assistance. The resident involved was an elderly individual with dementia, muscle wasting, dysphagia, severely impaired cognition, and limited functional range of motion in all extremities. Her Quarterly MDS documented that she required substantial/maximal assistance for eating, and her care plan identified her as being at risk for choking and aspiration related to difficulty swallowing, with instructions that her head of bed be elevated more than 45 degrees, with 90 degrees being optimal, during meals. On observation, the resident was receiving a pureed diet and required slow, assisted feeding with the head of bed elevated. Despite these needs, the facility allowed a newly hired CNA, on her first day of orientation, to assist this resident with eating without supervision. CNA F, who was assigned as the orienting CNA, reported that on the first day of orientation the new CNA assisted the resident with her meal and worked with her alone for 15 minutes. A family member later reported, based on video review, that the new CNA had worked with the resident for 45 minutes without supervision. The ADON stated that the first day of orientation should be shadowing only, with no hands-on care, and acknowledged that each resident has a profile that takes time to learn and that complications could arise from using the wrong technique or not following the care plan if staff are not properly trained. The facility’s own CNA orientation policy required appropriate instruction on any identified skill weaknesses prior to delivering or completing a task, which was not followed in this instance.
Failure to Maintain Dry Wound Dressing Prior to Medical Appointment
Penalty
Summary
A resident with a history of an unspecified wound on the left foot, left heel infection, and cognitive communication deficit was admitted to the facility. Physician's orders specified that the resident's wound dressing should not get wet during showers or baths, and that the area should be covered with a cast cover or plastic bag to prevent water exposure. On the day of a scheduled wound care appointment, the resident was assisted with a shower by a CNA, who reported wrapping the resident's left leg/foot in plastic. However, the resident's bandages were found to be wet upon arrival at the wound care appointment, as confirmed by a family member. The physician's orders also noted that the dressing had been soaked previously and reiterated the importance of keeping the dressing dry. Observation of wound care by an LVN later revealed that the dressings were dry and intact at that time, but the resident had open areas on the top of the foot and heel, with pain reported during the procedure. The DON confirmed in an interview that a wet dressing could lead to tissue breakdown and that the nurse should have changed the dressing if it was wet. The facility failed to ensure that the resident received care in accordance with professional standards and the comprehensive care plan, as the resident was sent to a medical appointment with a wet wound dressing, contrary to physician's orders.
Mechanical Lift Transfer Performed by Single Staff Member
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, contractures in both shoulders, and muscle wasting was transferred using a mechanical lift by a single staff member, despite the lift requiring two staff for safe operation. The resident, who was dependent on staff for all transfers and had limited functional range of motion in all limbs, was observed being lifted from a shower chair and moved approximately ten feet to her bed while suspended about three feet above the ground. During the transfer, the resident was visibly swinging as her weight shifted side to side. The Director of Nursing confirmed in an interview that two staff are required for mechanical lift transfers to prevent falls, but the facility's mechanical lift policy did not specify the number of staff required. The incident was captured on video, showing the single staff member performing the transfer and moving the resident through a 180-degree turn while she remained suspended in the air.
Failure to Administer Enteral Medications per Physician Order
Penalty
Summary
A deficiency occurred when a nurse failed to administer enteral medications according to physician orders for a resident with a gastrostomy tube. The nurse combined multiple medications into a single cup and administered them as a cocktail, rather than crushing and administering each medication separately with warm water as specified in the physician's order and facility policy. The nurse also did not use warm water for flushing the tube, as required by the order. The resident involved was an elderly female with multiple medical diagnoses, including unspecified dementia, gastrostomy status, hypertension, anemia, and hydronephrosis. Her care plan and medication administration record indicated that medications should be administered as ordered by the physician, with specific instructions to flush the tube with 30cc of warm water before and after administration. There was no order permitting the mixing of medications for enteral administration. Interviews with other nursing staff, the DON, and review of facility policies confirmed that the standard practice is to crush and administer each medication separately, flushing the tube with warm water between medications, unless otherwise ordered by a physician. Staff consistently stated that medications should not be mixed due to the risk of adverse reactions and tube clogging. The nurse involved acknowledged awareness of the correct procedure but attributed the error to nervousness during observation by a state surveyor.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or provide clear, measurable interventions.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure that each resident received an accurate assessment. The report notes that assessments were not completed accurately, which is required to determine the appropriate care and services for residents. Specific details about the residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report. The deficiency centers on the inaccuracy of resident assessments, which are essential for planning and delivering individualized care.
Unattended and Unlocked Medication Cart Exposes Medications
Penalty
Summary
A deficiency was identified when a medication cart in the 100 Hall was found unlocked and unattended in the hallway, exposing its contents to unauthorized access. The cart contained over-the-counter (OTC) medications, prescription medications, syringes, more than 30 lancets, and over 100 pen needles, as well as inhalation solutions, inhalers, and topical creams. The cart was left unattended by an LVN who stated she was interrupted by a resident request during medication pass, resulting in the cart being left unlocked and unsupervised. Interviews with the LVN and the Interim DON confirmed that facility policy requires medication carts to be locked when not in use and under direct supervision, to prevent unauthorized access, especially by cognitively impaired residents. Review of the facility's Medication Management policy further supported this requirement, stating that medication carts must be locked when not in use and that keys are to be kept with authorized staff. The failure to secure the medication cart was observed directly by surveyors and acknowledged by staff.
Failure to Provide Physician-Ordered Pureed Diet to Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a physician-ordered pureed diet due to dysphagia was served a mechanical soft lunch tray instead of the required pureed consistency. The resident's medical record indicated a history of difficulty swallowing, severe cognitive impairment, and a care plan specifying the need for a pureed diet to prevent choking and aspiration. Despite these documented needs, the resident was provided with the incorrect food texture during a meal service. The error originated in the kitchen, where the dietary aide, feeling rushed, misread the meal ticket and placed a mechanical soft plate on the tray instead of the pureed plate. The tray was then delivered to the resident's room by a CNA, who did not notice the inconsistency and began feeding the resident. The nurse was not present during the initial tray delivery and did not check the tray before feeding commenced. The CNA gave the resident one bite and attempted a second before the resident refused further intake by closing her lips. The mistake was identified when the nurse entered the room and recognized the resident was being fed the wrong diet. The tray was immediately removed, and the resident was assessed for any signs of aspiration or choking, with no adverse symptoms observed at that time. The incident was reported to supervisory staff, and the resident's physician and family were notified. The deficiency was attributed to failures in both dietary and nursing staff to verify the correct diet consistency before serving and feeding the resident.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevent new ulcers from developing for a resident, leading to the development of a stage 3 sacral pressure ulcer and an unstageable pressure injury on the right buttock. The resident, who was at risk for skin breakdown due to impaired mobility and incontinence, was not properly monitored or treated for skin issues. Despite the presence of redness on the resident's buttocks noted by a CNA, the LVN did not follow the facility's protocol to initiate adequate wound interventions or notify the appropriate personnel. The resident's care plan included specific instructions for pressure ulcer prevention and management, such as regular skin assessments and the use of barrier creams. However, the facility failed to ensure that comprehensive weekly skin assessments were completed, resulting in a delay in initiating wound care. The lack of documentation and communication among staff members contributed to the oversight, as the redness was not reported to the wound care nurse or the resident's physician in a timely manner. Interviews with staff revealed that there was a breakdown in communication and adherence to protocols. The treatment nurse was not informed of the redness until the wounds had progressed, and the floor nurses did not consistently perform or document the required skin assessments. The facility's failure to follow professional standards of practice placed the resident at risk of experiencing pain and possible infection from avoidable pressure wounds.
Failure to Provide Adequate Grooming Care for Resident
Penalty
Summary
The facility failed to provide adequate care and assistance for a resident who was unable to perform activities of daily living, specifically in maintaining good grooming. The resident, who had multiple medical conditions including dementia, hemiplegia, and functional quadriplegia, was found with a thick accumulation of a brown, flaky substance on her scalp and matted hair that required cutting. Additionally, her nails were not properly groomed, resulting in a dark brown/black substance accumulating underneath them. These issues were not documented in the resident's progress notes, and there was no indication that the resident refused care or that the facility staff attempted to address these grooming deficiencies. The resident's care plan indicated that she required substantial assistance with personal hygiene and was dependent on staff for various activities, including showering and hair care. Despite this, there was a lack of documentation and communication regarding the resident's grooming needs. Interviews with facility staff revealed that the resident's hair had been matted for an extended period, and there was no attempt to resolve the issue by cutting the hair or notifying the resident's responsible party (RP) or physician. The facility's policy on activities of daily living emphasized the importance of maintaining proper grooming and hygiene, yet these standards were not met in the resident's care. The failure to notify the resident's RP and physician about the grooming issues resulted in a delay in treatment and care. The resident's RP was unaware of the matted hair and scalp condition until the resident was admitted to an acute care hospital, where the RP had to cut the matted hair and attempt to clean the scalp. The facility's lack of communication and documentation regarding the resident's grooming needs placed the resident at risk for scalp itch, odors, infection, and undesirable haircuts, as noted in the report.
Wound Care Nurse Breaches Resident Privacy by Announcing Treatment in Hallway
Penalty
Summary
A deficiency occurred when a wound care nurse announced from the hallway, outside a resident's room, that she was about to perform wound care on the resident's sacrum. This announcement was made with the door half-open and within hearing range of others in the hallway. The nurse initially denied making the announcement but later acknowledged it, stating she was nervous and did not want to enter the room without the resident's permission. The resident, who is cognitively intact and fully dependent for care due to quadriplegia and other significant medical conditions, was not aware that his care had been announced in this manner but stated he would not want others to know about his personal medical issues. The facility's policy requires that residents be provided with both visual and auditory privacy during treatment and conversations. The administrator confirmed that announcing a resident's care from the hallway would be a dignity concern and could cause embarrassment. The incident was observed and confirmed during interviews with the nurse, the resident, and the administrator, and was found to be inconsistent with the facility's resident rights policy.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper wound care provided to a resident with a stage 4 pressure ulcer. During a wound treatment procedure, the Wound Care Nurse did not follow established protocols for hand hygiene and glove changes. Specifically, after removing the old dressing and cleansing the wound, the nurse did not change gloves before applying the new treatment and dressing, instead using the same gloves that had come into contact with the wound bed. Additionally, the nurse did not allow hand sanitizer to dry before donning gloves, which further compromised infection control practices. The resident involved was a male with multiple complex medical conditions, including quadriplegia, MRSA infection, and incontinence, and was totally dependent on staff for all activities of daily living. He had a documented stage 4 pressure ulcer on his sacrum, with ongoing wound management and regular assessments. The care plan and physician orders required specific infection control measures, including the use of personal protective equipment and proper hand hygiene during wound care procedures. Interviews with the Wound Care Nurse and the Nurse Consultant confirmed that the nurse did not follow facility policy or best practices for infection control during the wound care event. The nurse admitted to not changing gloves between wound cleansing and dressing application and acknowledged not allowing hand sanitizer to dry before gloving. The facility's wound care checklist and policy required glove changes and proper hand hygiene, which were not adhered to during the observed procedure.
Improper Food Storage in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A 13.7-quart container of brown sugar was found unlabeled and left open to the air, which could lead to contamination. This observation was made during a kitchen inspection, where it was noted that the container was not sealed, allowing potential contaminants such as chemicals and pests to enter. The lack of proper labeling and sealing of the container was acknowledged by the staff, including the Dietary Manager and the Administrator, who both recognized the risk of contamination and the potential for residents to become ill as a result. Interviews with the staff revealed an understanding of the risks associated with improper food storage. The staff member interviewed on December 18, 2024, acknowledged that leaving the container open could lead to contamination, which could make residents sick. The Dietary Manager also confirmed that the brown sugar was not covered or labeled, which could result in contamination and illness among residents. The facility's Nutrition Policies and Procedures, dated June 2023, require that opened packages be tightly sealed and that containers holding food removed from their original packaging be labeled with the common name of the food, which was not followed in this instance.
Failure to Coordinate PASRR Assessments for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure proper coordination of assessments with the Pre-Admission Screening and Resident Review (PASRR) program for one resident, identified as Resident #104. The deficiency occurred because the facility did not correctly identify Resident #104 as having a mental illness in her PASRR Level 1 Screening. This oversight was significant given Resident #104's medical history, which included diagnoses of metabolic encephalopathy, depression, major depressive disorder, and anxiety disorder. Additionally, she was prescribed antidepressant medications, Mirtazapine and Sertraline, and had a BIMS score indicating moderate cognitive impairment. The MDS Coordinator, who had been working at the facility for six months, acknowledged the discrepancy in the PASRR screening and mentioned that the process involved verifying diagnoses with the physician and filling out form 1012 if discrepancies were found. However, the MDS Coordinator was unsure why Resident #104's PASRR was missed, noting that there was supposed to be another MDS Nurse and a Corporate MDS Nurse to assist in checking the accuracy of records. The Corporate MDS Nurse confirmed that the hospital issued the initial PASRR and that the facility was responsible for identifying positive PASRRs and ensuring residents received necessary psych services. The facility's PASRR Documentation Policy required all applicants to be evaluated for serious mental disorders and to receive appropriate services, which was not adhered to in this case.
Improper Garbage Disposal Due to Unsecured Dumpster Lid
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, as observed with one of the two dumpsters used for garbage disposal. During an observation, it was noted that the lid of the dumpster on the left side was wide open. This observation was made in the dumpster area located at the back of the facility. Interviews with the facility's Cook and Dietary Manager confirmed that the staff is aware of the requirement to keep dumpster lids closed to prevent attracting pests such as bugs, flies, rodents, roaches, and raccoons. The Cook expressed concerns that if pests were attracted to the dumpster, they could potentially move towards the facility, posing a safety issue for residents. The facility's Nutrition Policies and Procedures, dated June 20, 2023, and the Food-Related Garbage and Rubbish Disposal policy, revised in April 2006, both emphasize the importance of keeping waste containers covered and dumpsters closed to prevent the transmission of disease and to avoid attracting pests. The policies also require that the area around dumpsters be kept clean and free of litter. Despite these policies, the failure to secure the dumpster lid was observed, indicating non-compliance with the facility's established procedures for waste disposal.
Failure to Verify G-Tube Placement and Administer Medications by Gravity
Penalty
Summary
The facility failed to ensure that a resident fed by enteral means received appropriate treatment and services to prevent complications of enteral feedings. Specifically, RN A did not verify the placement of the G-tube by aspirating stomach contents before administering water flushes and medications to Resident #85. Instead of allowing the flushes and medications to flow by gravity, RN A used a syringe plunger to administer them, which is against the recognized standards of practice. Resident #85, a male with a history of nontraumatic subarachnoid hemorrhage, dysphagia, aphasia, and cognitive communication deficit, was admitted to the facility with a gastrostomy tube for enteral nutrition. His care plan required enteral nutrition support to meet his energy, protein, and hydration needs, with specific instructions for water flushes and medication administration. However, during an observation, RN A failed to follow these instructions, potentially placing the resident at risk for adverse reactions and inadequate therapy. The Director of Nursing (DON) confirmed that RN A did not aspirate for residuals or administer medications by gravity, as required by the facility's policy and the Lippincott Nursing Procedures. The DON acknowledged the risks associated with not verifying tube placement and using a syringe plunger, which could lead to complications such as aspiration. The facility's policy mandates that licensed nurses administer medications by enteral tube using appropriate methods according to recognized standards of practice.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, as evidenced by the lack of labeling and dating of the resident's oxygen tubing and improper connection of the oxygen humidifier. The resident, a cognitively intact male with a history of nontraumatic intracranial hemorrhage, HIV, hemiplegia, hemiparesis, and COPD, was observed with his oxygen humidifier connected to his roommate's side of the room. The resident expressed concerns about the oxygen tubing being pinched and the risk of disconnection due to its placement, which could lead to difficulty breathing and anxiety. Interviews with facility staff, including an LVN and the DON, revealed a lack of adherence to the facility's oxygen therapy policy, which requires weekly changes and proper labeling of oxygen equipment. The LVN, who had been at the facility for one month, was unaware of the reasons for the discrepancies in labeling and dating. The DON confirmed the expectation for weekly changes and acknowledged the risk of infection and nasal cavity dryness if the humidifier ran out of water. The facility's administrator also emphasized the importance of following orders and policies for oxygen therapy to prevent infection control issues.
Inaccurate MDS Assessments for Resident Behaviors
Penalty
Summary
The facility failed to ensure accurate assessments of residents' behaviors on their quarterly Minimum Data Set (MDS) assessments, specifically for two residents. Resident #1, a female with multiple diagnoses including schizophrenia and depression, was noted in nurse's notes to have refused care on several occasions, such as refusing a blood sugar fingerstick and becoming combative when staff attempted to provide a shower. Despite these documented behaviors, her MDS assessment inaccurately reflected no behavioral symptoms or rejection of care. Resident #2, also a female with a diagnosis of dementia and anxiety, was similarly misrepresented in her MDS assessment. Although nurse's notes documented instances of her refusing care, such as declining a lidocaine patch and refusing assistance with personal hygiene and bed linen changes, her MDS assessment indicated no behavioral symptoms or rejection of care. Interviews with staff, including the MDS Coordinator and Social Worker, revealed a lack of awareness and oversight in accurately coding these behaviors on the MDS. The inaccuracies in the MDS assessments for both residents could potentially place them at risk for not receiving appropriate care and services tailored to their needs. The Social Worker admitted to missing documentation of the residents' behaviors during the MDS review process, which contributed to the inaccurate coding. The facility's failure to accurately assess and document these behaviors highlights a deficiency in the assessment process, which is crucial for ensuring residents receive the necessary care and interventions.
Deficiency in Resident's ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, a female with multiple medical conditions including chronic obstructive pulmonary disease, hypertension, diabetes, and cognitive impairment, required substantial assistance with toileting, bathing, and grooming. Despite these needs, observations revealed that the resident's personal hygiene was neglected, as evidenced by long and dirty fingernails and matted hair. Interviews with staff members highlighted inconsistencies in the care provided to the resident. A Certified Nursing Assistant (CNA) responsible for the resident's care admitted to not completing the cleaning of the resident's hands and reported the issue of long nails to a nurse. However, the nails remained untrimmed, and the resident's hands were observed to be dirty. The CNA also mentioned that the resident sometimes refused care, which contributed to the lack of grooming. Additionally, a Licensed Vocational Nurse (LVN) acknowledged the absence of a hand roll for the resident, which was necessary for her contracted hand. Further interviews with the Director of Nursing (DON) and other staff members confirmed the oversight in maintaining the resident's hygiene. The DON recognized the need for nail trimming and hair care but noted that aides were not permitted to cut nails, leaving the responsibility to the podiatrist or nursing staff. The lack of coordination and follow-through in addressing the resident's grooming needs resulted in the deficiency observed by surveyors.
Failure to Address Hand Contracture in Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion, specifically neglecting to implement interventions for a hand contracture. The resident, a female with multiple diagnoses including hemiplegia and severe cognitive impairment, was observed with a contracted right hand that lacked a hand roll, which is necessary to prevent further deterioration. The resident's nails were long, dirty, and pressed into the palm, indicating a lack of proper hygiene and care. Interviews with staff revealed that the resident's hand contracture was not being addressed adequately. A CNA responsible for the resident's care confirmed the absence of a hand roll and noted difficulties in maintaining the resident's hand hygiene. The CNA reported the issue of long nails to a nurse, but the problem persisted. An LVN acknowledged the need for a hand roll but was unaware of why it was not in place. The DON also recognized the need for nail trimming and the use of a hand roll, indicating a lapse in the facility's care protocols. The resident's care plan did not include interventions for the hand contracture, and the MDS Coordinator admitted that the care plan should have addressed range of motion issues. The facility's restorative nursing policies require assessment and implementation of a program to maintain or improve joint mobility, but these were not followed. The deficiency was identified when the resident was only picked up by therapy after the issue was brought to the facility's attention, highlighting a significant oversight in the resident's care management.
Failure to Maintain Sanitary Environment for Resident
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment for a resident, as evidenced by a strong smell of ammonia reported by the resident's family member. The family member discovered that the resident's underlay and nightgown were soaking wet with urine and left on the resident's wheelchair. This incident was reported on a weekend, and the family member had difficulty locating the weekend supervisor to address the issue immediately. The resident involved was an elderly woman with severe cognitive impairment, dementia, dysphagia, cellulitis, muscle wasting, and atrophy. She was dependent on staff for all activities of daily living (ADLs) and used a wheelchair. Her care plan included interventions for incontinence and skin protection, but the incident indicated a failure to adhere to these interventions, as the resident was left in an unsanitary condition. Interviews with staff revealed that a new aide, who was working for the first time after orientation, was responsible for the resident's care at the time of the incident. The aide reportedly forgot to remove the soiled linen from the resident's wheelchair. The weekend supervisor and other staff members were involved in addressing the family's concerns, but there was no clear determination of who was responsible for the oversight. The facility's grievance system recorded the incident, but there was no indication of immediate corrective actions or re-education for the staff involved.
Inadequate Pressure Ulcer Care Due to Supply Shortages and Protocol Failures
Penalty
Summary
The facility failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, Resident #3 did not receive adequate treatment for a stage 4 pressure ulcer on the right buttock, as the facility did not follow the physician's orders to apply Bactroban and Alginate. Additionally, the Assistant Director of Nursing (ADON) did not perform proper hand hygiene during wound care, increasing the risk of infection. The facility also lacked the necessary supplies, leading the ADON to make improvised dressings using gauze and tape instead of the prescribed materials. Resident #4 also experienced inadequate wound care due to the facility's failure to provide the necessary supplies. The resident's right hip stage 3 pressure ulcer was not treated with the appropriate dressings, and the ADON had to substitute with makeshift materials. Furthermore, a CNA did not perform proper perineal care or hand hygiene, which could contribute to the resident's risk of infection. The facility's central supply issues were highlighted by multiple staff members, who reported that the Administrator had restricted orders due to budget constraints, leading to a shortage of essential wound care supplies. Interviews with staff and observations revealed that the facility's wound care processes were compromised due to the lack of supplies and failure to follow physician orders. The Wound Care Nurse and other staff members confirmed that they had been using alternative materials for wound care due to the unavailability of the prescribed dressings. The facility's failure to maintain adequate supplies and adhere to proper wound care protocols placed residents at risk for worsening pressure ulcers and infections.
Failure to Provide Proper Incontinence and Catheter Care
Penalty
Summary
The facility failed to ensure proper care for residents who were incontinent of bladder, leading to increased risk of urinary tract infections. Specifically, CNA A did not practice proper technique while providing incontinence care for a resident. During the care, CNA A did not spread the resident's labia to thoroughly clean the area and the urinary meatus. Additionally, CNA A failed to perform hand hygiene while changing gloves, which could result in cross-contamination. CNA A admitted to not recalling any competency checks for incontinence care at the time of hire and missing the last infection control training due to being out with COVID-19. Another deficiency was observed when ADON A placed a catheter bag on the bed while performing wound care on the same resident. This action posed a risk of contamination and backflow of urine. The ADON acknowledged that the catheter bag should have been placed below the bed to prevent these risks. For another resident, the facility failed to ensure the use of a catheter strap, which is essential to keep the catheter from dislodging. The resident reported that the strap had been missing for a week, and the nurses had not replaced it. The absence of the strap could lead to urethral trauma and increased risk of infection. The ADON confirmed that it was the nurse's responsibility to replace the strap and acknowledged the potential risks associated with its absence.
Infection Control Deficiencies in Wound and Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to deficiencies in the care of two residents and the actions of two staff members. Specifically, the Assistant Director of Nursing (ADON A) did not perform proper hand hygiene when moving from a dirty to clean site while performing wound care on a resident with multiple stage 4 pressure ulcers. During the wound care, ADON A failed to wash or sanitize her hands after removing soiled gloves and before applying clean dressings, which could lead to cross-contamination and infection. This was observed during a wound care session where the ADON handled the resident's wounds without adhering to proper infection control protocols, such as washing hands between glove changes and after touching contaminated objects like scissors and the foley catheter. The ADON acknowledged the lapse in infection control during an interview, admitting that her actions placed the resident at risk for infections. Another deficiency was observed with a Certified Nursing Assistant (CNA A) who failed to properly change gloves and wash or sanitize her hands when providing incontinence care to a resident with dementia and a stage 3 pressure ulcer. CNA A did not spread the resident's labia to thoroughly clean the area and proceeded to touch clean items with soiled gloves. She also applied Vaseline to the resident's buttocks with soiled gloves and then touched the resident's clean shirt, brief, sheet, and blanket without performing hand hygiene. In an interview, CNA A admitted to not following proper infection control procedures and acknowledged that her actions could result in cross-contamination and infections. She also mentioned that she had not received recent training on proper incontinence care at the facility. The facility's infection preventionist, ADON B, confirmed that staff are expected to follow standard infection control techniques, including handwashing before treatments, between glove changes, and after moving from dirty to clean sites. However, it was noted that CNA A had missed the last infection control training due to being out with COVID. The facility's policies and procedures on infection prevention and control, as well as hand hygiene, were reviewed and found to be in place, but not adequately followed by the staff involved in these incidents.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #3, who has multiple medical conditions including quadriplegia, stage 4 pressure ulcers, and type 2 diabetes mellitus with hyperglycemia. The resident's care plan, which was supposed to ensure proper wound care, was not followed as the facility did not administer Bactroban and Calcium Alginate as ordered by the Wound Care Doctor on 01/11/2024. This oversight was observed during a wound care session on 01/14/2024, where the ADON did not apply the prescribed medications to the resident's wounds, despite the presence of signs of infection in the right buttock wound. The ADON also failed to maintain proper hand hygiene during the procedure, which could further compromise the resident's health. The ADON admitted to not being aware of the new orders due to a lapse in updating the electronic medical record (EMR) with the latest wound care doctor's recommendations. The Wound Care Doctor confirmed that Bactroban was ordered prophylactically due to the resident's incontinence and previous concerns about wound infections. The facility's policy on physician orders was not followed, leading to the resident not receiving the necessary medication and potentially delaying essential medical treatment.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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