The Belmont At Twin Creeks
Inspection history, citations, penalties and survey trends for this long-term care facility in Allen, Texas.
- Location
- 999 Raintree Circle, Allen, Texas 75013
- CMS Provider Number
- 676237
- Inspections on file
- 45
- Latest survey
- May 22, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at The Belmont At Twin Creeks during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of malnutrition, stroke, and swallowing difficulties did not receive the ordered ground diet and was not properly assisted during a meal. Staff failed to check the accuracy of the meal tray, did not ensure the resident was positioned upright, and did not provide the required supervision, resulting in the resident being served a whole sandwich instead of ground meat and being left unable to reach her food.
A resident receiving morphine for pain management experienced discrepancies in medication administration records and narcotic logs, with staff documenting doses as given when they were not, and saving unused half-tablets instead of destroying them with a witness. The facility did not update records to reflect the correct dose after a physician order change, and required signatures for drug destruction were missing, resulting in inaccurate controlled substance documentation.
A resident with cancer, bone fracture, and Parkinson's disease did not receive morphine for pain as ordered over several days due to discrepancies in medication administration and documentation. Staff inconsistently recorded doses, failed to properly waste unused narcotics, and did not update records after a change in the physician's order, resulting in missed doses and improper handling of controlled medications.
Staff failed to follow infection control protocols during incontinence care for two residents, including using soiled gloves to handle clean wipes and not performing hand hygiene between tasks. Both instances involved staff acknowledging they did not follow proper procedures, which was confirmed by facility leadership as being against policy.
A resident with a history of intracerebral hemorrhage and quadriplegia received PRN Xanax for anxiety on multiple occasions over a period exceeding 14 days, without a documented rationale for continued use or a specified end date. The DON confirmed that PRN psychotropic medications should not be prescribed for more than 14 days, but could not explain why the order remained active. The facility also lacked a written policy for PRN antianxiety/psychotropic medication use.
A resident discharged to another facility did not have a completed recapitulation of stay, with missing information from Social Services, Nursing, Activities, Dietary, and Rehabilitation departments. The discharge summary was neither completed nor signed, and the DON confirmed that each department was expected to complete their section, but no written policy was in place for this process.
A resident with mild cognitive impairment and a history of depression and fibromyalgia was subjected to verbal and physical abuse by a CNA during incontinent care. Despite the resident's protests and another CNA's presence, the abusive behavior continued, causing the resident to feel fearful. The incident was initially dismissed by the facility due to the CNA providing a false name, and it was only after the resident recognized the CNA during an activity that the issue was reported to the ADON and DON. The witnessing CNA failed to report the abuse immediately, contributing to the deficiency.
A resident with multiple health conditions did not receive routine dental care despite requests and referrals, leading to issues with her dentures. The facility's records lacked documentation of dental visits, and the social worker was unaware of the resident's dental needs.
A resident with mild cognitive impairment reported abuse by a CNA during care, which was witnessed by another CNA who failed to report it. The facility delayed reporting the incident to the State Survey Agency due to initial disbelief and confusion over the staff member's identity. This delay in reporting placed residents at risk.
A resident with severe cognitive impairment and multiple health conditions did not receive adequate foot care, as evidenced by pink areas, flaky skin, and discolored toenails. Despite a podiatry visit in July, observations in August showed ongoing issues. Interviews with staff and a family member revealed concerns about the adequacy of care, and the facility failed to provide a podiatry policy.
A medication administration error occurred when a resident received medications intended for another resident due to a CMA's mistake. The resident, who was cognitively intact and had a history of hemiplegia, was given Oxybutynin and Trazodone, leading to hospitalization after experiencing adverse symptoms. The error was discovered when a family member noticed the wrong room number on the medication cup.
The facility failed to maintain a clean and safe environment for two residents due to one resident's refusal of care, resulting in a strong urine odor in the shared room. Despite being moderately cognitively impaired and occasionally incontinent, the resident did not participate in a toileting program and refused assistance with hygiene and housekeeping. Staff documented refusals but did not implement effective interventions, and the care plan lacked strategies for maintaining cleanliness.
The facility failed to maintain an effective infection prevention and control program, as CNAs did not perform proper hand hygiene during incontinence care for two residents. Despite receiving training, CNAs changed gloves without washing hands, increasing the risk of infection. The DON confirmed the expectation for staff to follow hand hygiene protocols, and the facility's policy emphasizes its importance in preventing infections.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to improperly labeled and expired food items, dented cans not segregated, and unlabeled packages. The refrigerator and freezer contained uncovered and unlabeled food items, improperly stored chicken with blood leakage, and food with frostbite, placing residents at risk for exposure to adulterated or contaminated food.
The facility failed to change a resident's central line dressing weekly as required, missing a scheduled change and potentially risking infection. The resident had severe cognitive impairment and multiple diagnoses, including an infection of the humerus. Staff interviews and record reviews confirmed the lapse, with the DON unaware of the missed change and the RN admitting to not remembering specific orders.
A facility failed to report and investigate a resident's fall and injuries as required. The resident, with moderately impaired cognition, was found on the floor with multiple bruises and blood coming from her head. Despite the visible injuries and the resident's inability to explain the fall, the incident was not reported to the State agency, leading to a deficiency in ensuring resident safety and proper investigation.
A resident with bipolar disorder and anxiety disorder was admitted with a PASRR Level I indicating no mental illness, missing the required PASRR Level II evaluation. The resident was observed to be clean and well-groomed but visibly distressed. The Baseline Care Plan was found incomplete, highlighting deficiencies in the facility's assessment and care planning processes.
The facility failed to identify a resident with mental illness and did not complete a new PASRR Level I Screening, leading to the resident not receiving a necessary PASRR Level II evaluation. The resident had diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder, which were not captured in the initial screening.
The facility failed to develop and implement a baseline care plan for a newly admitted resident with bipolar disorder, major depressive disorder, and anxiety disorder. The resident's care plan was incomplete, lacking information on her care needs and status, which could result in staff not knowing how to best care for her. The facility's policy on baseline care plans was not provided.
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to a deficiency in meeting their individualized needs. One resident's care plan did not address his schizophrenia, and another resident did not have a care plan at all, potentially compromising their care and well-being.
A facility failed to ensure proper treatment for a resident with a feeding tube, as an LVN did not check for residual volume before administering medication. This oversight, confirmed by both the LVN and the DON, could lead to complications such as aspiration. The resident involved had severe cognitive impairment and multiple diagnoses, including Gastrostomy status and chronic kidney disease.
Failure to Provide Ordered Therapeutic Diet and Meal Assistance
Penalty
Summary
A resident with a history of stroke, diabetes, non-Alzheimer's disease, and malnutrition, who was cognitively impaired and required supervision while eating, did not receive the therapeutic diet ordered by her healthcare provider. The resident was supposed to be on a regular, ground diet with specific instructions for meal assistance and positioning due to swallowing problems. On the observed date, the resident was found lying in bed at a 30-degree angle, unable to reach all the food on her tray, and was served a whole sandwich instead of ground meat, contrary to her dietary order. Staff interviews revealed that the LVN was unaware of the resident's correct diet and had to check the order, while the ADON confirmed the resident should not have received a whole sandwich due to choking risk. The CNA who delivered the tray admitted to not checking the tray for accuracy or assisting the resident to sit up, citing being rushed. The dietician confirmed the resident was on a ground diet and that the kitchen and nursing staff were responsible for verifying the tray contents. The DON also acknowledged that the resident was not properly supervised and was at risk for choking if served the wrong diet. Facility policy required that all dining services staff follow the prescribed diet orders and ensure proper food texture and resident positioning. However, the failure to provide the correct diet, ensure proper tray delivery, and supervise the resident during meals led to the deficiency, as the resident did not receive the ordered therapeutic meal and was not assisted as required.
Failure to Maintain Accurate Narcotic Logs and Proper Destruction of Controlled Substances
Penalty
Summary
The facility failed to provide proper pharmaceutical services for a resident who was prescribed morphine for pain management related to cancer and a bone fracture. The resident had orders for morphine 15 mg to be given as half a tablet (7.5 mg) three times daily, with an additional as-needed order. However, discrepancies were found between the medication administration record (MAR) and the narcotic log, with the MAR documenting 19 doses administered and the narcotic log showing only 17 doses signed out. Staff interviews revealed that doses were sometimes documented as given in the MAR when they were not actually administered, and that the timing of administration did not always match the records. Further investigation showed that staff were saving the unused half-tablets of morphine instead of properly destroying them with a witness, as required by facility policy. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) were unaware that this practice was occurring until it was brought to their attention. The facility's narcotic records and morphine card were not updated to reflect the correct dose after the physician's order was changed, and staff did not use correction stickers or obtain a new dose card from the pharmacy as required. Additionally, there were missing signatures on the narcotic record, indicating that proper witnessing of drug destruction did not occur. Competency checks for medication aides (MAs) were on file, but the MAs admitted to documenting doses as given when they were not, and to saving half-tablets in the medication cart. The DON confirmed that staff should have contacted the pharmacy and physician to obtain the correct dose and documentation, and that two staff members were required to witness drug destruction. The facility's policies on pharmacy services and controlled medication management were not followed, resulting in inaccurate narcotic logs and improper handling of controlled substances.
Failure to Administer and Document Morphine Doses as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including cancer, bone fracture, and Parkinson's disease did not receive morphine as ordered for pain management over a period of nine days. The resident was cognitively intact and had a care plan that required administration of pain medications as ordered by the physician. The physician's orders specified morphine 15 mg, to be given as half a tablet (7.5 mg) three times a day, with an as-needed order also in place. However, discrepancies were found between the Medication Administration Record (MAR) and the Narcotic Record, with the total doses documented as administered not matching the doses signed out, and missing signatures for narcotic waste. The morphine card count was correct, but documentation and administration practices were inconsistent. Interviews with medication aides (MAs) and licensed vocational nurses (LVNs) revealed that doses were sometimes documented as given at times when they were not actually administered, and that staff did not always follow procedures for wasting the unused half-tablet of morphine. One MA admitted to documenting a dose as given at a scheduled time even though it was administered later, and another MA reported saving the half-tablet in the medication cart instead of destroying it with a witness, as required. Staff also reported confusion about whether doses had already been administered, leading to further discrepancies in documentation. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that staff were not consistently following procedures for narcotic destruction and documentation, and that the correct dose and records had not been updated promptly after the physician's order was changed. Facility policy required accurate reconciliation of physician orders upon admission, proper accounting for controlled medications, and destruction of unused narcotics with a witness. Despite these policies, the failure to administer morphine as ordered, improper documentation, and lack of adherence to controlled medication procedures resulted in the resident missing doses of pain medication. The resident was unaware of the missed doses and reported a pain level of 6 at the time of interview.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinence care for two residents. In the first instance, a cognitively intact female resident with a history of falls and incontinence required partial assistance with toileting. During observed care, a CNA washed her hands and donned gloves, but after cleaning the resident, she used soiled gloves to retrieve clean wipes from the container and did not perform hand hygiene after removing the soiled gloves. The CNA acknowledged she was aware of the correct procedure but did not follow it due to stress, recognizing the risk of infection to the resident. In the second instance, a cognitively impaired female resident with cancer and total incontinence also required partial assistance. During care, two CNAs washed their hands and donned gloves, but one CNA used soiled gloves to handle the wipes container and did not immediately change a soiled sheet after incontinence care, stating she would do so later because she was in a hurry. Both CNAs and facility leadership confirmed that these actions were not in accordance with facility policy, which requires glove changes and hand hygiene when moving from dirty to clean areas and prohibits touching clean supplies with soiled gloves.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from chemical restraints that were not required to treat medical symptoms. Specifically, a male resident with a history of nontraumatic intracerebral hemorrhage, quadriplegia, and restlessness/agitation was prescribed Xanax 0.5mg as a PRN antianxiety medication. The physician's order for Xanax did not specify an end date, and the medication was administered on multiple occasions over a period exceeding 14 days. There was no documented rationale for the continued provision of the medication beyond the 14-day period. The resident's care plan indicated the use of antianxiety medication for anxiety disorder, with goals to avoid discomfort or adverse reactions. However, the facility did not discontinue the PRN prescription after 14 days as required, nor did it document a justification for ongoing use. During an interview, the DON acknowledged the expectation that PRN psychotropic medications should not be prescribed for more than 14 days and was unable to explain why the order remained active. Additionally, the facility did not have a written policy regarding PRN antianxiety/psychotropic medication use.
Incomplete Discharge Summary and Recapitulation of Stay
Penalty
Summary
The facility failed to complete a discharge summary, specifically a recapitulation of stay, for a resident who was discharged to another facility. The recapitulation of stay was missing required information from multiple departments, including Social Services, Nursing Services, Activities, Dietary Services, and Rehabilitation Services. The document was neither completed nor signed, and this omission was identified during a review of the resident's records. The resident in question had a medical history that included a urinary tract infection, type 2 diabetes mellitus with hyperglycemia, and an unspecified head injury. During an interview, the DON stated that it was expected for each department to complete their respective sections of the recapitulation of stay, but was unsure why it had not been done in this case. The facility did not have a written policy regarding the completion of recapitulation of stays, but the administrator indicated that the facility was expected to follow state guidelines. The lack of a completed recapitulation of stay was noted as a deficiency in the resident's discharge process.
Failure to Protect Resident from Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a Certified Nursing Assistant (CNA) was witnessed being verbally and physically abusive. The incident involved a resident with mild cognitive impairment and a history of depression and fibromyalgia, who required extensive assistance with Activities of Daily Living (ADL). During an episode of incontinent care, the resident asked the CNA to stop rolling her over due to pain, but the CNA continued despite protests from both the resident and another CNA present. The resident reported feeling fearful and believed the CNA might harm her. The resident initially reported the incident to multiple staff members but was told that no one matching the CNA's description worked at the facility. It was later discovered that the CNA had provided a false name during the incident. The resident recognized the CNA during a facility activity and reported this to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON). The resident's family member also expressed frustration that the facility initially dismissed the resident's claims and installed a camera in the resident's room for added security. Interviews with staff revealed that another CNA witnessed the abuse but did not report it due to personal reasons. The facility's investigation was hampered by inconsistencies in the resident's account and the lack of immediate reporting by the witnessing CNA. The facility eventually identified the abusive CNA and took action, but the initial failure to protect the resident and the delay in addressing the abuse constituted a deficiency in ensuring the resident's right to be free from abuse.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that a resident received routine dental care, which was necessary for maintaining oral health and hygiene. The resident, an elderly female with multiple health conditions including Alzheimer's disease and multiple sclerosis, was dependent on staff for personal hygiene. Despite requests from the resident's representative for dental services due to issues with her top denture, the resident had not been seen by a dentist. Observations confirmed that the resident's top denture was not secured and kept sliding down, and she did not recall receiving any dental services. The facility's records showed that a referral for dental services had been made, but there was no documentation indicating that the resident was seen by a dentist. The social worker, responsible for ensuring the resident received dental services, was unaware of whether the resident had been seen and noted that the resident was not on her dental list. The facility's policy stated that routine and emergency dental services should be available to meet residents' oral health needs, but this was not adhered to in the case of the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse and neglect were immediately reported to the State Survey Agency, as required by regulations. This deficiency was identified in the case of a resident who reported an incident involving two CNAs. The resident, who had mild cognitive impairment and required extensive assistance with activities of daily living, reported that one CNA was verbally abusive and physically rough during incontinent care, causing her pain and fear. Despite the resident's report to multiple staff members, the incident was not immediately reported to the appropriate authorities. The incident was initially dismissed by the facility because the resident provided a name and description that did not match any known staff member. It was only after the resident recognized the CNA during a later encounter that the facility began to take action. Interviews with staff revealed that another CNA had witnessed the abuse but failed to report it due to personal feelings about the perpetrator's living conditions. This failure to report was a significant factor in the delay of the investigation and notification to the State Survey Agency. The facility's administration, including the DON and Administrator, were informed of the incident but did not report it to the State Survey Agency within the required timeframe. The Administrator believed the resident was confused and did not feel the abuse was intentional, which contributed to the delay in reporting. The facility eventually conducted an internal investigation, but the initial failure to report the alleged abuse in a timely manner placed residents at risk of further harm.
Deficiency in Resident Foot Care
Penalty
Summary
The facility failed to provide appropriate foot care for a resident, leading to a deficiency in maintaining good foot health. The resident, a severely cognitively impaired elderly female with multiple health conditions, required maximal assistance with mobility and was dependent on staff for activities of daily living. Her care plan included preventative measures for pressure ulcer prevention, such as skin prep to her toes and the use of a pressure redistribution mattress. However, the facility did not ensure consistent application of these measures, as evidenced by the presence of pink areas and flaky skin on her toes, as well as curled and discolored toenails. The resident's medical records indicated that she had been seen by a podiatrist in July, who performed a complete foot examination and toenail debridement. Despite this, observations in August revealed ongoing issues with her foot care, including pink areas and flaky skin on her toes. Interviews with the treatment nurse and the Director of Nursing (DON) suggested that the resident's toes appeared better than in previous months, yet there was a lack of clarity regarding the specific wound care being provided. The treatment nurse acknowledged that the resident would benefit from routine skin prep, which was intended to harden the skin on her toes. Interviews with facility staff and a family member highlighted concerns about the adequacy of the resident's foot care. The family member reported that the resident had wounds on her toes in July, which were not being adequately addressed by the facility. The DON admitted that the appearance of the resident's toes could have been improved with lotion and acknowledged the risk of skin breakdown. Despite requests, the facility did not provide a podiatry policy, indicating a potential gap in their procedures for ensuring proper foot care.
Medication Administration Error
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications, resulting in a medication error involving two residents. A resident received medications, Oxybutynin and Trazodone, that were prescribed for another resident. This error occurred when a Certified Medication Aide (CMA) mistakenly administered the wrong medication cup to the resident after being distracted from the medication cart. The resident who received the incorrect medications was a cognitively intact female with a history of hemiplegia following a cerebral infarction. The error was discovered when a family member noticed the medication cup was labeled with another resident's room number. Despite attempts to have the resident spit out the medication, she had already swallowed two pills. The resident was subsequently monitored for adverse reactions, and her condition deteriorated, leading to hospitalization. The incident was documented in progress notes, indicating that the resident experienced slurred speech, muscle weakness, and decreased oxygen saturation, which required medical intervention and hospitalization. The facility's policy on medication administration, which includes verifying the right patient and medication, was not adhered to, leading to this deficiency.
Failure to Maintain a Clean and Safe Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for two residents, specifically in maintaining a room free of urine odors. Resident #4, who shared a bathroom with Resident #5, was noted to have a room with a strong smell of urine. This was due to Resident #4's refusal to allow staff to assist with personal hygiene, change bed linens, or clean the room. The resident was moderately cognitively impaired and occasionally incontinent of urine, yet did not participate in a urinary toileting program. The facility's records indicated multiple instances where Resident #4 refused care, including housekeeping services, which contributed to the unsanitary conditions. Staff documented the resident's refusals but did not record any effective interventions to address the situation. The resident's care plan did not adequately address the physical environment, focusing instead on minimizing resistance to care without specific strategies for maintaining cleanliness. Interviews with staff, including the DON and Housekeeping Supervisor, revealed ongoing challenges in managing Resident #4's care refusals. Despite attempts to encourage participation in activities and physical therapy to facilitate room cleaning, the resident continued to decline assistance. The facility was in the process of seeking alternative placement for the resident due to her non-compliance and worsening dementia, but no immediate solutions were implemented to resolve the environmental issues.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during incontinence care for two residents. CNA A and CNA B did not perform proper hand hygiene during the care of residents, which is a critical step in preventing the spread of infections. Specifically, CNA A did not wash her hands or use hand sanitizer after removing gloves while providing care to a resident with severe cognitive impairment and multiple health conditions, including a current urinary tract infection. Similarly, CNA B failed to wash her hands or use hand sanitizer between glove changes while caring for another resident with intact cognition and a history of incontinence. The observations revealed that CNA A, who was orienting a new CNA, did not adhere to the hand hygiene protocol despite having received training on infection control and hand hygiene two months prior. During the care of a resident with a suprapubic catheter, CNA A changed gloves without washing hands, increasing the risk of infection. CNA B, who also received similar training, repeated the same mistake by not washing hands between glove changes while applying barrier cream and cleaning the perineal area of another resident. The Director of Nursing (DON) confirmed that the CNAs were expected to follow hand hygiene protocols, which include washing hands upon entering and exiting resident rooms and with glove changes. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing the spread of infections. The DON also noted that there had been recent cases of E. coli in urine cultures, which could be linked to improper wiping techniques during incontinence care.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. During an initial tour of the dry storage area, several deficiencies were observed, including improperly labeled and expired food items, dented cans not segregated, and unlabeled packages of tea bags. Additionally, the facility's refrigerator and freezer contained uncovered and unlabeled food items, improperly stored chicken with blood leakage, and food with frostbite. These observations indicate a lack of adherence to proper food storage and labeling protocols, which could potentially expose residents to adulterated or contaminated food. Interviews with the Head Cook and Dietary Manager revealed that the Dietary Manager was responsible for ensuring proper food storage and training staff on food storage procedures. However, the observations made during the survey indicated that these responsibilities were not adequately fulfilled. The Head Cook and Dietary Manager acknowledged the issues and stated that they had taken steps to address them, but the deficiencies were still present at the time of the survey. The facility's failure to adhere to the U.S. Public Health Service Food Code and the U.S. Department of Health and Human Services Food Code was evident in the improper storage, labeling, and handling of food items. This non-compliance with food safety standards placed the majority of the facility's residents at risk for exposure to adulterated or contaminated food, which could lead to severe health effects such as diarrhea, nausea, allergic reactions, diabetes, and cardiovascular disease.
Failure to Timely Change Central Line Dressing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident, specifically in the management of a central line. The central line dressing for a resident was not changed per the physician's order and facility policy, which required weekly changes to prevent infection. The resident, who had severe cognitive impairment and multiple diagnoses including an infection of the humerus and hypertensive heart disease, had a central line for antibiotic administration. The dressing was changed on 01/19/24 but was not changed again until 02/02/24, missing the scheduled change on 01/26/24. This lapse was confirmed through record reviews and interviews with staff, including an RN who acknowledged the failure to change the dressing timely and the DON who was unaware of the missed dressing change but stated it should have been done weekly to prevent infection. The deficiency was further highlighted by the lack of a care plan for the central line and incomplete physician orders regarding the frequency of dressing changes. The responsible RN admitted to not remembering if there were specific orders for the dressing change and only changed the dressing once during the resident's stay. The DON also admitted to not following up on the central line dressing changes, which were crucial for preventing infections. The facility's policy on dressing changes did not specify the frequency, contributing to the oversight and potential risk to the resident's health.
Failure to Report and Investigate Resident Fall
Penalty
Summary
The facility failed to ensure all allegations of abuse were reported immediately to the State agency, thoroughly investigated, and residents were protected during the investigation. This deficiency was identified for one resident who was found alone on the floor in her room with multiple bruises on her face. The resident, who had a BIMS score indicating moderately impaired cognition, was unable to verbalize how the fall occurred. Despite the visible injuries and the resident's inability to explain the fall, the facility did not report the incident to the State agency, as they believed it did not meet the criteria for reporting. Interviews with various staff members, including an RN, LVN, receptionist, and aide, revealed that the resident was found on the floor with blood coming from her head. The staff provided immediate care, including cleaning the wound and performing neurological checks, but did not report the incident as required. The facility's administrator, who is also the Abuse Coordinator, confirmed that the incident was not reported, stating it did not meet the criteria for reporting. The facility's Reportable Incident Protocol Policy requires that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, be reported to the State agency within five working days. The policy defines injuries of unknown source as those not observed by any person or not explained by the patient, and suspicious due to the extent or location of the injury. Despite this policy, the facility failed to report the incident involving the resident's fall and injuries, leading to a deficiency in ensuring resident safety and proper investigation of potential abuse or neglect.
Deficiency in PASRR Process and Incomplete Baseline Care Plan
Penalty
Summary
The report identifies a deficiency related to the Pre-Admission Screening and Resident Review (PASRR) process for a resident. The resident, a female with diagnoses including bipolar disorder and anxiety disorder, was admitted to the facility with a PASRR Level I completed at the hospital, which indicated no mental illness. However, upon review, the MDS Coordinator found that the resident's diagnoses of bipolar disorder and anxiety disorder were not included in her medical history, which should have necessitated a PASRR Level II evaluation. This oversight was confirmed during an interview with the MDS Coordinator, who acknowledged that the resident should have received a PASRR Level II evaluation but did not believe there were any immediate risk factors due to this omission. Throughout the survey process, the resident was observed to be clean, well-groomed, and appropriately dressed, with no visible marks or bruises. Despite being alert and oriented, the resident was visibly distressed and grief-stricken due to recent traumatic events, including her own illness and the death of her daughter. The Baseline Care Plan for the resident, initiated by an RN/Charge Nurse, was found to be incomplete, with no areas filled out. This incomplete documentation further highlights the deficiency in the facility's assessment and care planning processes for the resident.
Failure to Complete PASRR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that individuals with mental disorders were properly evaluated and received care in the most integrated setting appropriate to their needs. Specifically, the facility did not correctly identify a resident as having a mental illness and did not complete a new PASRR Level I Screening. This oversight was discovered during a review of the resident's face sheet and MDS assessment, which indicated diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder. However, the PASRR Level I Screening completed prior to the resident's admission did not reflect any indicators of mental illness. During an interview, the resident expressed satisfaction with the care received but was visibly distressed and grief-stricken due to recent traumatic events. The MDS Coordinator confirmed that the PASRR Level I Screening was completed at the hospital and did not capture the resident's mental health diagnoses. The coordinator acknowledged that the resident should have received a PASRR Level II evaluation based on her diagnoses but was unaware of any risk factors due to the lack of this evaluation.
Failure to Implement Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for Resident #95 within 48 hours of her admission. Resident #95, a [AGE] year-old female with diagnoses including bipolar disorder, major depressive disorder, and anxiety disorder, was admitted to the facility on [DATE]. Her MDS Assessment indicated she required assistance with activities of daily living (ADLs) such as bathing and dressing. However, her baseline care plan, dated 02/14/24, was found to be incomplete with no information regarding her care needs or status at the time of admission. During an interview, the Administrator confirmed that the expectation was for baseline care plans to be completed upon a resident's admission by the nursing staff. The failure to complete Resident #95's baseline care plan could result in staff not knowing how to best care for her. The facility's policy regarding baseline care plans was requested but not provided by the Administrator.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to a deficiency in meeting their individualized needs. Resident #08, a male with diagnoses including dementia, psychotic disturbance, anxiety disorder, and schizophrenia, had an incomplete care plan that did not address his schizophrenia. Despite being prescribed Seroquel for schizophrenia, this diagnosis was not included in his care plan, which could prevent him from receiving necessary care. The MDS coordinator admitted to overlooking the diagnosis, and the DON acknowledged that missing information in the care plan could result in missed care needs. Resident #35, a female with acute kidney failure, hypertension, type 2 diabetes mellitus, and other conditions, did not have a care plan at all. Despite being alert and oriented with a BIMS score of 15, her care needs were not documented. The LVN responsible for completing the care plan admitted to missing it, and the DON confirmed that she had not checked if the care plan was completed. This lack of documentation could lead to staff not meeting the resident's care needs. The facility's policy requires a comprehensive person-centered care plan to be developed within seven days of the MDS assessment and updated regularly. However, the failure to adhere to this policy for Residents #08 and #35 indicates a lapse in the facility's processes, potentially compromising the residents' care and well-being.
Failure to Check Residual Volume Before Medication Administration
Penalty
Summary
The facility failed to ensure that residents who are fed by enteral means receive appropriate treatment and services to prevent complications. Specifically, LVN F did not check for residual volume prior to administering medication to a resident with a feeding tube, as required by the physician's order. This oversight could lead to complications such as aspiration, which occurs when food, liquid, or other material enters a person's airway and eventually the lungs by accident. The resident in question, a [AGE] year-old female with severe cognitive impairment and multiple diagnoses including Gastrostomy status, hypertension, type 2 diabetes, and chronic kidney disease, was observed receiving medication without the necessary residual volume check. During an interview, LVN F admitted to forgetting to check for residual volume, acknowledging the importance of this step in preventing overfeeding and ensuring proper digestion. The Director of Nursing (DON) confirmed that the residual check is crucial for verifying the feeding tube's placement and preventing aspiration. Despite the facility's policy on administering medication through an enteral tube and recent in-service training, the required procedure was not followed. The facility's policy did not address checking for residual, which contributed to the oversight.
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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