Texoma Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman, Texas.
- Location
- 1000 Hwy 82 E, Sherman, Texas 75090
- CMS Provider Number
- 455573
- Inspections on file
- 41
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Texoma Healthcare Center during CMS and state inspections, most recent first.
Surveyors identified that kitchen staff failed to consistently record hot and cold food temperatures on required logs, did not maintain cold holding temperatures for milk, and did not follow proper glove use to prevent cross-contamination between raw chicken and ready-to-eat sliced cheese. Temperature logs were incomplete for multiple meals, and milk on prepared trays was found above the required 41°F threshold. A dietary aide handled raw chicken and then touched sliced cheese with the same gloves before serving a meal to a resident, contrary to facility policy and FDA Food Code requirements for single-use gloves and time/temperature control for safety foods.
A resident with dementia, dysphagia, protein-calorie malnutrition, and no teeth had a care plan and orders addressing swallowing problems and diet needs, including a renal diet and prior use of mechanical soft texture. The resident’s meal ticket listed a mechanical soft renal diet with crushed pineapple for dessert, but dietary staff assembled the tray with Nilla Wafer cookies instead, and the tray was passed through nursing and activities without correction. The resident reported lacking teeth and said he could eat the cookies only with enough water and preferred the crushed pineapple listed. Interviews with the Dietary Manager, DOR, RNs, and Regional Nurse showed conflicting information about whether the resident should be on regular vs mechanical soft diet, reliance on communication forms that were not completed or available, and a breakdown in the process for communicating and verifying diet orders between speech therapy, nursing, and dietary, resulting in the dessert not matching the ordered diet on the meal ticket.
Significant ice accumulation on the walk-in freezer door prevented it from latching properly for an extended period. Dietary staff had to manually de-ice the freezer daily, and there was no written schedule or log for this task. Despite recent repairs to the door handle and seal, the issue persisted, and maintenance was unaware of the ongoing problem. The facility lacked a specific policy for freezer maintenance, contributing to the deficiency.
A treatment nurse failed to perform hand hygiene between glove changes and after removing gloves while providing wound care to a resident with a pressure wound and multiple comorbidities. The nurse handled wound care supplies and personal items without sanitizing hands as required by facility policy, only washing hands at the end of the procedure.
A resident with severe cognitive impairment and multiple comorbidities was given a shower by two CNAs despite repeatedly refusing and expressing distress. The CNAs physically transferred the resident and proceeded with the shower, disregarding her care plan and facility protocols that required staff to honor refusals and notify a nurse. The incident was confirmed by the resident, her roommate, and staff interviews, and resulted in significant emotional distress for the resident.
Two residents with severe cognitive impairment and mental health needs experienced mental anguish when one was physically forced by CNAs to shower despite repeated refusals, and the other was upset after overhearing the incident. Both residents' care plans included trauma-informed interventions and the right to refuse care, but staff proceeded with the shower regardless, resulting in documented distress.
Several residents' care plans did not reflect their preferences for bed baths or their repeated refusals of showers, even though staff were aware and had documented refusals elsewhere. Additionally, a resident with declining vision and a need for cataract surgery did not have her vision needs or related care documented in her care plan, despite ongoing efforts to arrange appointments. These omissions resulted in care plans that did not accurately describe the services to be provided, as required by facility policy.
A facility failed to maintain an effective pest control program, resulting in recurring ant infestations in resident rooms, common areas, and the exterior perimeter. One resident with multiple health conditions was bitten by ants found in her room and bed. Staff used a QR code system to report pest issues, but these were not consistently communicated to the pest control company, and the facility lacked a written pest control policy. The pest control company was not always informed of all pest-related work orders, leading to ongoing pest problems.
A resident with multiple chronic conditions and cognitive impairment experienced a decline in vision and was identified as needing cataract surgery, but the facility did not complete a comprehensive significant change assessment within the required timeframe. The resident's MDS and care plan did not reflect her vision issues, and staff interviews revealed a lack of documentation and understanding regarding the assessment and reporting of vision impairment.
A controlled medication blister pack on a nurses cart was found with a broken seal and the pill still inside, taped over, rather than being discarded as required. The RN responsible did not check blister pack integrity during narcotic counts and was unaware of when the seal was broken. The DON confirmed that such medications should be discarded and that staff are responsible for checking for broken seals during shift changes.
A deficiency was identified when the ice machine's drip tray in the dining room was found with grayish slime, mold, and a used, soaked paper napkin, indicating a failure to follow professional standards for food service safety. Staff interviews revealed uncertainty about the last cleaning, and cleaning logs showed inconsistent adherence to the required daily sanitation schedule.
The facility failed to provide weekend activities for residents, leading to boredom and lack of socialization. Nine residents reported no activities on weekends except for church services. The Activities Director cited the absence of an Activities Assistant since August 2024 as a reason for the deficiency. The facility's policy requires ongoing activities based on residents' interests, but records showed several weekends with no planned activities. Bed-bound residents also reported not being offered one-on-one activities.
A facility failed to provide necessary wound care to three residents, leading to a deficiency in care. A resident with pressure ulcers did not receive treatment for two days, confirmed by both the resident and treatment nurse. Another resident with a stage 3 ulcer also missed care on the same days, despite usually receiving daily treatment. A third resident, at high risk for ulcers, did not have his wound treated, and the missing dressing was noted by staff. The LVN responsible admitted to not completing the care and not seeking help.
The facility failed to accommodate the food preferences of two residents, leading to dissatisfaction with meals. A resident with diabetes and malnutrition reported receiving the same breakfast daily without choice, while another resident received sausage despite preferring bacon. Staff interviews revealed a lack of communication and adherence to resident preferences, contradicting facility policy.
The facility's kitchen failed to store, label, and date food items in accordance with professional standards, as observed in the walk-in refrigerator. Items such as hamburger patties, onions, carrots, cheese slices, and tortillas were not properly managed, posing a risk of cross-contamination. The Dietary Manager and kitchen staff acknowledged their responsibility for these tasks, which are crucial for preventing foodborne illnesses.
A resident with cognitive impairment and medical needs did not receive scheduled showers, as documented in the facility's records. Staff interviews revealed lapses in communication and documentation, with a CNA forgetting to shower the resident and another staff member incorrectly documenting care. The DON acknowledged the responsibility of CNAs and charge nurses to ensure showers were given and documented, noting the risk of skin issues and loss of dignity.
A resident with a gastrostomy tube was observed receiving a water flush at 60 ml/hr instead of the prescribed 50 ml/hr, posing a risk of hydration concerns. The RN confirmed the discrepancy, and the DON emphasized the importance of matching tube feed pump settings with physician orders.
A facility failed to provide proper pharmaceutical services, resulting in medication errors for two residents. An LVN did not prime an insulin pen before administering it to a resident with diabetes, risking incomplete dosage. Another resident, receiving nutrition via a G-tube, was given combined medications against facility policy, which requires separate administration with water flushes. The facility's DON and Pharmacy Consultant confirmed the importance of following these procedures to ensure accurate medication delivery.
A resident with severe cognitive impairment and multiple medical conditions was transported to the hospital after becoming unresponsive, but the facility failed to immediately notify the resident's representative. The resident's representative was informed by the hospital days later, impacting her ability to make timely medical decisions. The failure occurred because the responsible RN forgot to contact the family at the end of her shift.
Two residents in an LTC facility did not receive scheduled showers, leading to a deficiency in care. A moderately cognitively impaired female and a severely cognitively impaired male were both scheduled for regular showers but did not receive them consistently. Staff interviews revealed issues with documentation and communication, resulting in missed showers. The facility's policy on bathing was not followed, risking skin issues and loss of dignity for the residents.
A resident did not receive several medications upon admission due to the facility's failure to order them in a timely manner. The medications were not available in the emergency kit, and the pharmacy was not contacted after hours to expedite the order. The resident, who was severely cognitively impaired and had multiple diagnoses, missed doses of important medications, highlighting a lapse in the facility's pharmaceutical services.
Failure to Maintain Food Temperatures and Prevent Cross-Contamination in Kitchen
Penalty
Summary
The deficiency involves failures in food storage, preparation, and handling practices in the facility’s only kitchen, specifically related to temperature monitoring and cross-contamination prevention. During an observation of the kitchen, the surveyor requested hot and cold food temperature logs and found that temperatures were not thoroughly taken or recorded on multiple dates for various food items, including milk and juice beverages, side dishes of fruits and vegetables, and meat entrées. The Dietary Manager acknowledged the incomplete temperature logs and stated that bolded items on the log were supposed to be temperature checked, and that hot foods must be 145°F and higher and cold foods 41°F and lower to prevent spread of illness and contamination. Facility policy required temperatures of all hot and cold foods to be taken prior to every meal service and recorded on the Temperature Log, with hot foods held at 140°F or above and cold foods less than 41°F. Further observations during lunch preparation showed that staff did not consistently maintain cold holding temperatures and did not follow proper glove use to prevent cross-contamination. Two lunch trays were observed with cups of milk that were not held to maintain cold temperatures, and when the milk temperature was checked, it measured 52.7°F. In another observation, a dietary aide donned new gloves to handle raw chicken tenders and, without changing gloves, then touched sliced cheese and placed it on a hamburger intended for a resident. When questioned, the dietary aide stated that touching raw meat and then sliced cheese could get someone sick. The facility’s written procedures and the referenced FDA Food Code required single-use gloves to be used for only one task, such as working with raw animal food or ready-to-eat food, and required time/temperature control for safety foods to be maintained at 135°F or above for hot holding and 41°F or less for cold holding.
Failure to Follow Ordered Diet Texture and Dessert for Resident With Dysphagia
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services provided met professional standards of quality by not following the comprehensive care plan and diet orders for one resident. The resident was an older man with dementia with psychotic disturbance, dysphagia, and unspecified protein-calorie malnutrition, and required dentures. His care plan identified a potential nutritional problem and a swallow problem related to dysphagia, with instructions for staff to monitor for swallowing difficulties and to ensure the prescribed diet was followed, with goals of no choking episodes and no signs of aspiration. Record review showed an active physician order for a renal diet with regular texture and regular consistency, and a discontinued order for a renal diet with mechanical soft texture. However, during meal tray preparation, the resident’s meal ticket listed a renal diet with mechanical soft texture and specified a dessert of 1/2 cup crushed pineapple. Instead of the ordered crushed pineapple, the tray was assembled with a cup of Nilla Wafer cookies as dessert and passed from dietary to an RN and then to the activities director for delivery. When observed, the resident, who did not have teeth, stated he could eat the cookies only if he drank enough water and indicated he preferred the crushed pineapple listed on his meal ticket. Interviews revealed inconsistent understanding and communication of diet orders among staff. The Dietary Manager stated that Nilla Wafers were considered safe for mechanical soft diets when served with pudding and that dietary staff relied on written communication forms from nursing or speech therapy for diet changes; he reported having no such form for this resident. The Director of Rehabilitation stated the resident had been evaluated by speech therapy and was on a regular diet with thin liquids, and that speech therapy did not communicate diet orders directly to the kitchen, expecting nursing to complete and deliver diet order forms. RN A reported relying on dietary staff’s statement that Nilla Wafers were mechanical soft, was unaware of the regular diet order in the chart, and described a process in which nursing created and sent diet sheets to dietary. RN B stated the resident could eat a regular diet but was supposed to be on mechanical soft due to not using dentures, and did not recall completing a communication form for a regular diet order. The Regional Nurse described expectations that dietary staff and nurses check meal tickets and meals before delivery and that speech-initiated diet changes be entered into the chart and confirmed by nursing before being sent to dietary, underscoring that this process was not effectively followed for this resident’s dessert.
Failure to Maintain Walk-In Freezer in Safe Working Condition
Penalty
Summary
Surveyors observed significant ice accumulation on the walk-in freezer door, with ice measuring 1 to 3 inches in width and covering various parts of the doorway, preventing the door from latching properly. Dietary staff reported that the issue had persisted for about two months and had worsened in the last month, requiring them to manually de-ice the freezer daily. The inability to latch the freezer door was directly attributed to the ice buildup, and staff confirmed that the door could not be closed fully due to this accumulation. The Dietary Manager acknowledged that the excess ice and inability to latch the door placed food at risk for contamination, freezer burn, and deterioration, and also confirmed there was no log or written schedule to ensure regular de-icing by staff. Maintenance records indicated that while the door handle and seal had been replaced, the problem persisted, and a contractor had not yet completed necessary repairs. The Maintenance Supervisor was unaware that the door was still not latching properly. Review of facility policy showed that while there was a policy for refrigerator maintenance, there was no specific policy for freezer maintenance or storage. The lack of a clear maintenance protocol and failure to ensure the freezer door could latch properly led to ongoing ice accumulation and potential food safety risks.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for one resident. During an observed wound care procedure, the treatment nurse did not perform hand hygiene between glove changes or after removing gloves, despite handling various supplies and touching the resident's wound. The nurse also did not use hand sanitizer prior to entering the resident's room or after removing gloves at several points during the procedure. The nurse handled items such as a tube of medicated ointment, gauze, dressings, and a marker without performing hand hygiene between tasks, and only washed her hands at the end of the procedure after disposing of trash. The resident involved was an elderly male with a history of a left femur fracture, hypertension, and chronic kidney disease, and had a pressure wound on his left heel. The resident had severely impaired cognition and required wound care as part of his treatment plan. The facility's infection control policy required hand hygiene before and after changing dressings and after removing gloves, but these protocols were not followed during the observed wound care event.
Resident's Right to Refuse Shower Not Honored
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, chronic obstructive pulmonary disease (COPD), Alzheimer's disease, chronic pain syndrome, and anxiety disorder was not treated with respect and dignity regarding her right to refuse care. On the evening in question, the resident verbally refused a shower multiple times, stating she was cold and did not want a shower. Despite her refusals, a CNA physically lifted her from the bed by her armpits, placed her in a shower chair, and, with the assistance of another CNA, proceeded to shower her. The resident continued to express her refusal and distress throughout the process, including stating she would contact her attorney and the police. The resident's care plan specifically included interventions to immediately stop if she refused a shower, and to avoid touching her if she was escalated, unless necessary for safety. Multiple interviews and record reviews confirmed that the resident was able to communicate her wishes and had the capacity to make informed decisions. Staff statements and documentation indicated that the CNAs were aware of the resident's right to refuse a shower and the facility's policy for handling refusals, which included notifying a nurse and completing a refusal form. However, the CNA disregarded these protocols, insisting the resident would feel better after a shower and proceeding without her consent. The incident was corroborated by the resident's roommate, who overheard the exchange, and by subsequent interviews with other staff members who acknowledged that forcing a resident to shower against their will was a violation of resident rights. The event resulted in the resident feeling angry and distraught, as documented in her statements to staff, the social worker, and a psychologist. The resident reported the incident to her nurse, family, and external parties. Progress notes and interviews indicated that the resident had no physical injuries directly attributed to the incident, but she experienced significant emotional distress. The facility's policies on resident rights and bathing clearly outlined the necessity of honoring resident preferences and refusals, but these were not followed in this instance, leading to the identified deficiency.
Failure to Prevent Abuse and Honor Resident Refusals During Showering
Penalty
Summary
The facility failed to ensure that residents were free from abuse, specifically for two residents with severe cognitive impairment and mental health diagnoses. One resident, who had a history of trauma, chronic pain, COPD, Alzheimer's disease, and anxiety disorder, was physically lifted from her bed by a CNA under her armpits and given a shower despite her repeated verbal refusals. The resident expressed anger and mental anguish as a result of being forced to shower against her will. Documentation and interviews confirmed that the resident was able to communicate her wishes and had the capacity to make informed decisions at the time of the incident. Another resident, who was the roommate of the first, also experienced mental anguish after overhearing the incident. This resident, who had diagnoses including cancer, heart failure, stroke with paralysis, and major depressive disorder, reported being upset by hearing her roommate being forced to shower by staff. Both residents were on mental health services, and their care plans included interventions for cognitive impairment and trauma-informed care, including respecting refusals and stopping care if the resident became escalated. Staff interviews and record reviews revealed that the CNAs involved were aware of the residents' right to refuse care but proceeded with the shower regardless. The incident was reported by the affected resident to nursing staff and was corroborated by her roommate and other staff members. The event was documented in progress notes, care plans, and verbal statements, and was identified as Immediate Jeopardy Past Noncompliance by surveyors. The actions of the staff directly contradicted the residents' expressed wishes and established care plan interventions, resulting in documented mental distress for both residents.
Failure to Include Resident Preferences and Vision Needs in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately described the services to be furnished to meet the highest practicable physical, mental, and psychosocial well-being of four residents. Specifically, the care plans did not reflect the residents' preferences and needs regarding bathing and vision care. For three residents with severe cognitive impairment and significant physical limitations, their repeated refusals of showers and preferences for bed baths were not documented in their care plans, despite staff being aware of these preferences and having residents sign shower refusal forms. Interviews with staff confirmed that these residents commonly refused showers, and the process for documenting refusals was inconsistently followed, with some refusal forms missing from the medical records. Additionally, one resident with a history of cataracts and declining vision did not have her vision needs or the need for eye care and surgery reflected in her care plan. Although there were physician orders and ongoing efforts by the social worker to arrange necessary eye appointments and surgery, these needs were not documented in the care plan. Staff interviews revealed a lack of awareness and communication regarding the resident's vision impairment, and the care plan did not include interventions or plans to address her vision needs. The facility's policies required that care plans be person-centered and include measurable objectives and timeframes to meet residents' identified needs. However, the care plans reviewed did not include the residents' preferences for bathing or their vision care requirements, despite these being known to staff and relevant to the residents' well-being. This omission resulted in care plans that did not fully describe the services to be provided, as required by facility policy and regulatory standards.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement and maintain an effective pest control program, resulting in the presence of ants in resident rooms, on the exterior perimeter of a resident hall, and in multiple locations throughout the building. In one instance, a resident with multiple medical conditions, including hypertension, diabetes, and a surgical site, was found to have ants in her room and on her bed, leading to two pinpoint bites on her thighs. The nurse who discovered the ants noted that the insects were coming from the window seal, and the resident had open food in the room at the time. Documentation confirmed the presence of ant bites, and the resident was subsequently moved to another facility. Observations and interviews revealed that an ant hill was present on the exterior perimeter near a resident hall, close to a resident room window. The Maintenance Director acknowledged the ant hill and reported an increase in work orders for ants, attributing it to hot weather. The facility's pest control company provided monthly services and responded to additional requests, but the pest control binder and maintenance logs were not consistently shared with the pest control company. The Maintenance Director handled most complaints internally and did not provide the maintenance log, which tracked pest-related work orders, to the pest control company. This lack of communication limited the pest control company's awareness of all pest issues in the facility. Record reviews showed multiple entries in both the pest control binder and the maintenance task report documenting recurring ant problems in various rooms and common areas. Staff interviews indicated that pest sightings were reported through a QR code system, but these reports were not always transferred to the pest control binder or communicated to the pest control company. The facility did not have a written pest control policy, and the Administrator confirmed that logs from the QR code system were not routinely provided to the pest control company. The absence of a comprehensive and coordinated pest control program resulted in ongoing pest issues and placed residents at risk for infection and decreased quality of life.
Failure to Complete Significant Change Assessment for Vision Decline
Penalty
Summary
The facility failed to ensure that a resident who experienced a significant change in condition, specifically a decline in vision, was comprehensively assessed within 14 days as required. The resident, an older adult with diagnoses including Type 2 Diabetes Mellitus, Hypertension, and Cognitive Communication Deficit, was noted in a physician's progress note to have cataracts and was recommended for follow-up with an ophthalmologist for possible surgery. Despite this, the resident's Quarterly MDS assessment did not reflect any vision impairment or use of corrective lenses, and her care plan did not mention vision issues or the need for eye care or surgery. Interviews and record reviews revealed that the resident expressed difficulty seeing, required eyeglasses, and reported urgent need for an eye doctor due to declining vision. The social worker made several attempts to arrange an eye exam and surgery, but was unsuccessful due to transportation challenges related to the resident's size and a fall during a previous transport attempt. These efforts were not documented in writing. The MDS nurse stated that vision issues were not included in the MDS because there was no formal diagnosis from an eye doctor, despite a nurse practitioner's note mentioning cataracts. Other staff, including the ADON and Administrator, were either unaware of the vision decline or unsure of the requirements for documenting vision impairment in the MDS. The facility did not have a specific policy for MDS assessments and relied on the RAI Manual. The DON acknowledged that vision impairment should be noted on the MDS and that failure to do so could result in the resident not receiving necessary eye care. The RAI Manual outlines the importance of assessing and documenting vision impairment and the use of corrective lenses, but these steps were not followed for this resident, resulting in the deficiency.
Failure to Properly Label and Secure Controlled Medications on Nurses Cart
Penalty
Summary
Surveyors observed that drugs and biologicals on the D hall Nurses Cart were not labeled and stored in accordance with professional standards. Specifically, a blister pack containing APAP/codeine 300-30 mg tablets for a resident had one blister seal broken, with the pill still inside and taped over. The RN responsible for the cart stated that while narcotic counts were performed at shift change, she did not check the integrity of the blister packs during the count and was unaware of when or how the seal was broken. The RN acknowledged that nurses are responsible for checking for broken seals during shift changes and that any broken-seal medication should be wasted with another nurse present. The DON confirmed that any medication with a broken blister pack seal should be discarded and that it was not acceptable to keep a pill in an opened blister pack, citing risks of drug diversion and infection control. The DON also stated that nurses are responsible for checking medication blister packs during shift changes and that ADONs are expected to randomly monitor the carts. Facility policy requires that medications in containers without secure closures be immediately removed and disposed of according to procedures.
Failure to Maintain Sanitary Conditions of Ice Machine
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically regarding the cleanliness and sanitation of the dining room's ice machine. During observation, the ice machine's drip tray was found to have a buildup of grayish slime or mold and contained an old, used, and soaked paper napkin. The dietary staff member interviewed was unable to recall the last time the machine had been cleaned and sanitized and had to refer to the daily cleaning schedule log. The cleaning schedule indicated that the ice machine was supposed to be sanitized daily before each meal, but the log showed inconsistent cleaning dates over a two-week period. Interviews with staff, including the dietary staff and the administrator, confirmed that it was the responsibility of dietary, housekeeping, and administrative staff to ensure the beverage bar machines, including the ice machine, were kept clean and sanitized. The facility's policy required the ice machine to be cleaned and sanitized according to the manufacturer's instructions to prevent food contamination and the growth of disease-producing organisms. The observed failure to maintain the ice machine in a sanitary condition placed residents at risk of food contamination and foodborne illness.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide activities that meet the interests and support the physical, mental, and psychosocial well-being of residents during weekends. This deficiency was identified through observations, interviews, and record reviews, revealing that nine residents did not have access to weekend activities, except for church services on Sundays. The lack of weekend activities was confirmed during a group interview with residents who expressed boredom and a desire for more activities on Saturdays and Sundays. The Activities Director acknowledged the absence of weekend activities, attributing it to the departure of the Activities Assistant in August 2024. Since then, the facility has struggled to offer consistent weekend activities. The Activities Director mentioned that activities of resident choice were listed on the calendar for weekends, but these primarily involved residents playing games they already owned. The Solarium provided puzzles and books, but there were no organized activities facilitated by staff or volunteers on weekends, except for occasional events like church group visits or activities led by the Activities Director herself. Interviews with the Administrator and record reviews further highlighted the issue. The Administrator stated there were no plans to hire a new Activities Assistant and acknowledged the risk of boredom and lack of socialization for residents. The facility's policy on activity programming emphasized the need for ongoing activities based on residents' interests, but the records showed several weekends with no planned activities. Additionally, bed-bound residents reported not being offered one-on-one activities, although they had access to some in-room materials.
Failure to Provide Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatment to three residents, leading to a deficiency in the quality of care. Resident #82, a moderately cognitively impaired male with diabetes and a history of hip replacement surgery, had two pressure ulcers upon admission. His treatment plan required wound care twice daily, but no treatment was provided on two consecutive days. The resident confirmed that the staff did not treat his wound during the specified times, and the treatment nurse later confirmed the lapse in care. Resident #21, a cognitively intact female with diabetes, heart failure, and a seizure disorder, had a stage 3 pressure ulcer and other skin damage. Her treatment plan required daily wound care, which was not administered on the same two days as Resident #82. The resident noted the unusual absence of her wound care over the weekend, despite typically receiving it daily. The treatment nurse observed minimal drainage from the resident's wound, indicating a lack of recent care. Resident #85, a cognitively intact male with heart failure and malnutrition, was at high risk for pressure ulcers. His treatment plan required daily wound care for an ulcer on his coccyx, but no care was provided on the same two days as the other residents. The Assistant Director of Nursing (ADON) was alerted to the missing dressing on the resident's wound, and it was confirmed that the wound care was not performed. The Licensed Vocational Nurse (LVN) responsible for the lapse admitted to not completing the wound care and failing to seek assistance, leading to the deficiency.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodates resident preferences for two residents, leading to dissatisfaction with meals. Resident #76, a moderately cognitively impaired male with diabetes and malnutrition, expressed dissatisfaction with the repetitive breakfast menu and lack of choice. Despite being on a regular texture diet, he reported receiving the same breakfast items daily without being consulted on his preferences. The Dietary Manager admitted to making menu changes without resident input, and the dietician was unaware of the residents' complaints. Resident #31, also moderately cognitively impaired with diabetes and hyperlipidemia, reported receiving sausage daily despite her preference for bacon. She expressed confusion over the lack of variety and the facility's failure to honor her requests consistently. The facility's weekly menu for November showed the same breakfast items daily, contradicting the policy that requires offering a variety of food and accommodating resident preferences. Interviews with staff revealed a lack of communication and adherence to resident preferences. The Dietary Manager and Administrator acknowledged the repetitive breakfast menu but did not ensure residents were informed of changes or given choices. The facility's policy requires documenting menu changes and offering alternatives, but this was not consistently practiced, leading to potential dissatisfaction and poor intake among residents.
Failure to Properly Store and Label Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the walk-in refrigerator were not properly covered, labeled, or dated. This included hamburger patties, sliced raw onions, petite cut carrots, cheese slices with mold-like growth, and tortillas. These lapses were identified during an observation on November 18, 2024, at 7:50 AM. The Dietary Manager acknowledged that the responsibility for dating and labeling food items fell on both the cooks and himself, and he confirmed that the expectation was for all food items to be marked with a received date and a use-by date for leftovers and opened items. Interviews with kitchen staff, including a dietary aide and a cook, revealed that they were aware of the importance of covering, dating, and labeling food items to prevent cross-contamination and potential foodborne illness. The facility's policy on food safety, although undated, required that all food be wrapped or sealed, labeled, dated, and stored properly, with perishable opened foods to be used within seven days. The Food and Drug Administration Food Code also mandates that refrigerated, ready-to-eat time/temperature control for safety food must be clearly marked with a date or day by which it should be consumed, sold, or discarded.
Inconsistent Hygiene Care for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living, received consistent hygiene care, specifically showers or baths. The resident, a moderately cognitively impaired male with a BIMS score of 10, required substantial to maximum assistance with bathing due to his medical conditions, including diabetes and aftercare following hip replacement surgery. Despite being scheduled for showers on specific days, the resident did not receive showers on multiple occasions in November 2024, as documented in the facility's records. Interviews with the resident and staff revealed that the resident had only received one shower in a week and had to request it multiple times. Staff interviews indicated lapses in communication and documentation. A CNA admitted to forgetting to shower the resident and failing to document a refusal when the resident declined a shower at a later time. Another staff member incorrectly documented that the resident received a shower, despite not providing it. The facility's DON acknowledged the responsibility of CNAs and charge nurses to ensure showers were given and documented, and noted the risk of skin issues, hygiene problems, and loss of dignity for residents not receiving scheduled showers. The facility's policy emphasized the importance of regular bathing for maintaining skin integrity and cleanliness.
Incorrect Water Flush Administration for Enteral Nutrition
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was administered the correct water flush as per the physician's orders. The resident, a male with multiple health conditions including hypertension, cerebrovascular accident, gastrostomy status, malnutrition, respiratory failure, and aphasia, was observed to have a tube feeding pump set to deliver a water flush at 60 ml/hr instead of the prescribed 50 ml/hr. This discrepancy was noted during an observation and interview with a registered nurse (RN), who confirmed that the pump settings did not match the physician's orders. The RN acknowledged that the incorrect settings posed a risk of hydration concerns and decreased quality of care for the resident. The Director of Nursing (DON) also stated that the expectation was for the tube feed pump settings to match the physician's orders and that all nurses were responsible for ensuring the accuracy of the tube feeding infusions. The facility's policy on enteral nutrition emphasized providing nutritionally complete feedings as ordered by the physician, highlighting the importance of adhering to prescribed orders to prevent complications.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration errors. For Resident #15, a cognitively intact female with diabetes mellitus, the Licensed Vocational Nurse (LVN) did not follow the manufacturer's instructions for the Lantus Insulin Pen. The LVN administered 20 units of insulin without priming the pen, which is necessary to ensure the removal of air and the delivery of the full dose. The LVN acknowledged awareness of the priming requirement but failed to perform it during the medication pass. For Resident #97, a moderately cognitively impaired female receiving nutrition through a feeding tube, the LVN did not adhere to physician orders and facility procedures for administering medications. The LVN combined Sertraline and Levothyroxine in one medication cup, contrary to the requirement to administer each medication separately with a water flush in between. Although the LVN corrected the administration of other medications, she did not separate the Sertraline and Levothyroxine, citing the small volume of Levothyroxine as the reason. The facility's Pharmacy Consultant confirmed that best practice is to administer each medication separately to avoid potential incompatibility issues. Interviews with the Director of Nursing (DON) and the Pharmacy Consultant highlighted the importance of following established procedures to ensure residents receive the correct medication dosages. The DON emphasized that the facility's policy requires individual administration of medications with water flushes between each when using a G-tube, unless otherwise ordered by a physician. The failure to adhere to these procedures could result in residents not receiving the full amount of medication ordered.
Failure to Notify Resident's Representative of Emergency Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who was transported to the hospital via ambulance after becoming unresponsive. The resident, a male with severe cognitive impairment and multiple medical conditions including cerebral infarction, metabolic encephalopathy, and chronic obstructive pulmonary disease, was found somnolent and minimally responsive by RN-A, who then contacted the physician and arranged for emergency transport. Despite the critical nature of the situation, the resident's representative was not informed by the facility until several days later, after the hospital had already contacted her. The resident's representative was informed by the hospital that the resident was on a ventilator and had significant medical issues, including imbalances in sodium and blood sugar levels, and an elevated white blood count. The facility's failure to notify the family immediately could have impacted the ability of the resident's representative to make timely medical decisions. Interviews with facility staff, including RN-A and the Assistant Director of Nursing, revealed that the notification failure was due to RN-A forgetting to contact the family at the end of her shift. The facility's policies on family notification and resident rights emphasize the importance of timely communication with resident representatives in the event of significant changes in condition, but these procedures were not followed in this instance.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically showers and baths, for two residents who were unable to perform these tasks independently. Resident #2, a moderately cognitively impaired female with a history of stroke and joint replacement surgery, was scheduled to receive showers three times a week but did not receive them on multiple occasions throughout July 2024. Despite being scheduled for showers, the resident reported going over two weeks without one, citing a lack of towels and washcloths as reasons given by aides. Interviews with staff revealed inconsistencies in documentation and communication regarding the resident's care. Resident #3, a severely cognitively impaired male with dementia and chronic kidney disease, also did not receive scheduled showers on numerous occasions in July 2024. The resident expressed that he had not been receiving his showers as scheduled, and observations confirmed he was wearing the same clothing over consecutive days. Staff interviews indicated a lack of clarity and communication about who was responsible for providing the resident's showers, with aides assuming others had completed the task and failing to document or report missed showers to the charge nurse. The facility's policy on bathing, which emphasizes the importance of maintaining hygiene and skin integrity, was not adhered to, as evidenced by the lack of consistent bathing for these residents. The Director of Nursing acknowledged the responsibility of CNAs and charge nurses to ensure residents receive their scheduled showers and the importance of documenting any refusals or missed care. The failure to provide consistent hygiene care could lead to skin issues, hygiene problems, and a loss of dignity for the residents involved.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in missed doses of several medications. Upon admission, the resident did not receive Anastrozole, Liothyronine Sodium, Bupriopion HCL ER, Cefadroxil, and Propranolol as ordered by the physician. This was due to the facility staff not ordering the medications in a timely manner, leading to their unavailability when needed. The resident, who was severely cognitively impaired and had a history of malignant neoplasm, was admitted with diagnoses including hypertension, hypothyroidism, a bacterial infection, and PTSD. The facility's staff failed to ensure that the medications were ordered and available upon the resident's admission, which resulted in missed doses the following morning. The medications were not available in the emergency kit, and the pharmacy had not been contacted after hours to expedite the order. Interviews with facility staff and the contracted pharmacy revealed that the facility had recently changed pharmacies and was still adjusting to the new procedures. The staff did not follow the protocol of calling the pharmacy after hours to ensure timely delivery of medications. The Director of Nursing acknowledged the oversight and noted that the pharmacy procedure was posted at each nurse's station, outlining the ordering protocol.
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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