The Harrison At Heritage
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 4600 Heritage Trace Parkway, Fort Worth, Texas 76244
- CMS Provider Number
- 676317
- Inspections on file
- 66
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at The Harrison At Heritage during CMS and state inspections, most recent first.
Two residents did not have full visual privacy due to incomplete or improperly installed bed curtains. One resident's curtain only partially covered the bed, and another's left the foot of the bed exposed. Staff were unaware of the deficiency and had not reported it, and there was no specific policy addressing privacy curtains.
A resident was prescribed PRN Alprazolam for anxiety without a required 14-day stop date, contrary to facility policy. The medication order was entered after hospital readmission, but neither the admitting nurse nor subsequent reviews by the DON and ADON ensured compliance with the 14-day limitation. The resident's care plan did not reflect the use of this medication, and no doses were administered during the review period.
A resident with end-stage renal disease receiving regular dialysis did not have her dialysis treatment accurately coded in the MDS assessment, despite documentation and interviews confirming her ongoing treatment. The MDS Coordinator acknowledged missing this information, and the DON confirmed the expectation for accurate and timely assessments.
A resident with multiple fractures and functional limitations was not provided with a comprehensive care plan that included the use of a back brace and bilateral foot protectors, despite these being necessary interventions. Staff interviews revealed uncertainty about care planning responsibilities, and the omission was not identified until the survey, contrary to facility policy requiring all assessed needs and interventions to be care planned.
A resident admitted with a back brace and bilateral foot protectors did not have physician orders for these devices, despite their use being confirmed by the resident and staff. The care plan did not address the use of the braces, and staff interviews revealed uncertainty about the existence of necessary orders. The deficiency was identified when it was found that required physician orders had not been obtained or documented in accordance with facility policy.
A resident with severe cognitive impairment and a history of stroke received tube feedings at a rate higher than the physician-ordered 55 ml/hour, with staff administering 60 ml/hour and failing to update or clarify the order in the system. Nursing staff and management acknowledged the discrepancy, and facility policy required adherence to physician orders for enteral nutrition administration.
Two residents receiving dialysis did not have physician orders in place for their dialysis treatments or for pre- and post-dialysis vital sign monitoring, despite care plans indicating the need for such care. Staff interviews and record reviews confirmed the absence of these orders, and management was unaware until an audit revealed the deficiency.
A nurse prepared morning thyroid medications for a resident with severe cognitive impairment but left the medication cup unattended on a hallway handrail after being distracted by another resident. The nurse failed to return and administer the medications, which were later found by another nurse. This incident resulted in the resident missing prescribed doses and violated facility policy requiring proper medication administration and observation.
A resident with moderate cognitive impairment and a history of anxiety and stroke was found with a call light cord around his neck after expressing suicidal statements. Staff intervened, removed potential hazards, and arranged for psychiatric evaluation, but the incident was not reported to the State agency as required by facility policy.
A resident with moderate cognitive impairment and a history of anxiety and stroke was found with a call light cord around his neck, expressing suicidal ideations. Staff intervened promptly to ensure safety and arranged for psychiatric evaluation, but the required reporting of the incident to the State Survey Agency was not completed as mandated by facility policy and state law.
A nurse failed to treat a resident with dignity and respect by raising her voice and scolding the resident for repeatedly using the call light, despite the resident's severe cognitive impairment and need for assistance. Video evidence and interviews confirmed the nurse's inappropriate behavior, which did not align with the facility's policy on resident rights and respectful treatment.
Staff failed to wear required gowns while providing direct care to a resident on enhanced barrier precautions, despite clear signage and policy. Interviews revealed gaps in staff knowledge and training, and records showed the involved staff had not attended EBP training.
A resident was transferred to the hospital without receiving written notification of the transfer, reasons, or appeal rights, and the Ombudsman was not informed. The resident, with intact cognition, was transferred due to altered mental status, but no written documentation was provided. Facility staff were unaware of the requirement for written notices, despite policy guidelines.
A resident requiring substantial assistance for transfers was left unsupervised in a mechanical lift by a CNA who failed to obtain the required assistance from another staff member. The resident, with intact cognition and multiple diagnoses, was left suspended in the lift sling while the CNA sought help, contrary to the facility's policy requiring two staff members for such transfers.
The facility failed to ensure accurate narcotic logs and remove expired medications, leading to discrepancies in medication counts for several residents. Nurses admitted to not signing off on narcotic administration records, and expired medications were found in the Central Supply cabinet. The ADON and DON acknowledged the importance of proper documentation and oversight but lacked evidence of recent corrective actions.
The facility failed to provide palatable and appetizing food during a lunch meal, with observations revealing flavorless pureed vegetables and bland grilled chicken. Despite resident feedback indicating food was often cold and tasteless, the Dietary Manager and Regional Dietitian reported no prior complaints. The facility's policy on maintaining appetizing food was not followed.
The facility failed to properly label and date food items in the freezer and refrigerator, risking food contamination. Additionally, the ice machine in the 300-hall nutrition room had a brown substance on a flap touching the ice, indicating a lack of cleanliness. These deficiencies could lead to foodborne illnesses among residents.
A facility failed to update a resident's care plan to reflect current diet orders, leading to a mismatch between the care plan and the actual diet provided. The resident, with severe cognitive impairment and multiple health issues, had a diet order that was not accurately documented in the care plan. Staff interviews revealed a lack of communication and responsibility in ensuring care plans matched diet orders, despite the facility's policy requiring such updates.
A resident with multiple health conditions was not provided with scheduled showers, resulting in a disheveled appearance and soiled bedding. Staff interviews revealed a lack of documentation and accountability for the resident's hygiene care, despite facility policies requiring consistent care and documentation. This failure placed the resident at risk of infection.
A facility failed to ensure proper labeling of IV medication bags and tubing for a resident, leading to potential medication errors. The resident, who was receiving IV medication through a PICC line, had unlabeled IV bags and tubing, contrary to facility policy. An LVN admitted to not labeling the equipment despite being aware of the requirement, and the DON confirmed the expectation for labeling to prevent errors.
A facility failed to maintain accurate clinical records for a resident regarding catheter care. Despite orders to discontinue the catheter, progress notes inaccurately documented its presence. Observations and interviews confirmed the absence of a catheter, highlighting discrepancies in documentation. The facility's policy requires accurate records, which was not followed, potentially leading to miscommunication about the resident's care.
A resident with chronic pain and opioid dependence was not allowed to choose a new pain management provider despite expressing dissatisfaction with the current NP. The resident reported his concerns to an LVN, but facility policy was cited as a barrier to changing providers. The interim DON and administrator were aware of the issue but did not take timely action, leading to a deficiency in honoring the resident's rights.
A resident with a history of dementia and other medical conditions was left unsupervised in 96-degree heat for about two hours, resulting in unresponsiveness, second-degree burns, and heat stroke. The facility failed to implement a comprehensive care plan addressing the resident's behavior of wanting to sit outside, leading to severe consequences.
A resident with a history of dementia and other medical conditions was left unattended in 96-degree heat for about two hours, resulting in unresponsiveness, second-degree burns, and heat stroke. Despite being cautioned about the heat, the resident was left unsupervised on the patio, leading to hospitalization. The facility failed to document staff checks or interventions, highlighting a lack of supervision and adherence to care plans.
A facility failed to secure medications properly, leading to a deficiency in medication storage practices. An LVN left a resident's IV and injection medications unattended on a medication cart in the hallway, with the cart unlocked and accessible to unauthorized individuals. The resident required insulin and IV antibiotics for conditions including cellulitis and diabetes. The DON and ED confirmed that the facility's policy mandates securing medications in locked carts, which was not followed in this instance.
A medication cart in the facility was left unlocked and unattended by an LVN, allowing two residents to pass by it. The LVN admitted the cart should have been locked to prevent unauthorized access. Interviews with the DON and ED confirmed the expectation for carts to be locked at all times, but the facility could not provide a specific policy on medication security.
A resident with cognitive impairment and an unsteady gait was left alone in her room by a hospice aide, resulting in a fall that caused multiple lacerations and a wrist injury. Despite being identified as a high fall risk and having specific care plan interventions, the resident was not adequately supervised, leading to the incident.
Failure to Provide Full Visual Privacy Due to Inadequate Bed Curtains
Penalty
Summary
The facility failed to ensure that each bed had ceiling-suspended privacy curtains that provided total visual privacy for two residents. Observations revealed that one resident's curtain only partially covered his bed, leaving more than half exposed, and the resident expressed concern about being seen during incontinence care. The curtain had been insufficient since the resident's admission. Another resident's curtain separated his bed from his roommate but left the foot of the bed exposed, and staff interviews confirmed that privacy was not fully maintained during care. Staff, including CNAs, housekeeping, and maintenance, were unaware of the need for additional or adjusted curtains and had not reported the issue. The DON confirmed that privacy curtains should provide full coverage and that staff were responsible for notifying the appropriate departments if curtains needed to be changed or installed. There was no specific policy addressing privacy curtains, only a general policy on maintaining a safe and homelike environment.
PRN Psychotropic Medication Ordered Without Required 14-Day Stop Date
Penalty
Summary
A deficiency occurred when a resident was prescribed a PRN psychotropic medication, Alprazolam, for anxiety without a required 14-day stop date. The medication order was initiated upon the resident's readmission from the hospital and entered into the facility's system without specifying a stop date, as required by facility policy and regulatory guidelines. The resident's care plan did not reflect the use of this anti-anxiety medication, and medication administration records showed that the resident had not received any doses of the PRN Alprazolam during the review period. Interviews with nursing staff and the Director of Nursing (DON) confirmed that all PRN psychotropic medications must have a 14-day stop date to allow for reassessment and reevaluation of the medication's appropriateness. The admitting nurse did not ensure the stop date was included, and subsequent checks by the DON and ADON did not identify the omission. The facility's policy clearly stated the requirement for a 14-day limitation on PRN psychotropic orders unless specifically extended by the prescriber, but this was not followed in this instance.
Failure to Accurately Code Dialysis in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident who was receiving dialysis treatment. Specifically, the MDS for a female resident with end-stage renal disease and hypertension did not indicate that she was undergoing dialysis, despite her care plan and interviews confirming that she received dialysis three times a week. The resident's care plan included multiple interventions and monitoring related to her dialysis treatment, and the resident herself confirmed her ongoing dialysis schedule and the facility's involvement in her care. Interviews with the MDS Coordinator revealed that dialysis treatment was not coded in the resident's MDS assessment due to an oversight, and the Coordinator acknowledged responsibility for the error. The Director of Nursing confirmed that MDS Coordinators are expected to complete assessments accurately and on time, and recognized that missing information in the MDS could result in incomplete capture of the resident's care needs. The facility's policy required comprehensive assessments using the current RAI, including special treatments and procedures such as dialysis.
Failure to Include Back Brace and Foot Protectors in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with a back brace and bilateral foot protectors. The resident's admission assessment documented multiple fractures, muscle weakness, and functional limitations in both upper and lower extremities, with an intact cognitive status. Despite these needs, the care plan did not address the use of the back brace or foot protectors, even though the resident required the back brace when out of bed and the foot protectors while in bed. Observations confirmed the resident was using these devices as part of his care, and interviews with the resident and staff indicated that staff assisted with their application as needed. Interviews with nursing staff, the MDS Coordinator, the Unit Manager, and the DON revealed a lack of clarity regarding responsibility for updating care plans and whether such interventions should be included. The MDS Coordinator and DON both acknowledged that the back brace and foot protectors should have been included in the care plan, as they were interventions provided by the facility. However, the omission was not identified until the survey, and the facility's policy required all services identified in the comprehensive assessment to be included in the care plan with measurable objectives and timeframes.
Failure to Obtain Physician Orders for Orthopedic Devices
Penalty
Summary
A deficiency occurred when a resident with a history of multiple fractures, including an unspecified fracture of the third thoracic vertebra and muscle weakness, was admitted to the facility with a back brace and bilateral foot protectors. The resident was cognitively intact and required the back brace when out of bed and foot protectors while in bed, as confirmed by both the resident and staff. Despite this, the resident's care plan did not address the use of these devices, and there were no physician orders for either the back brace or the foot protectors in the resident's medical record at the time of review. Staff interviews revealed that both CNAs and nurses were aware of the resident's need for the back brace and foot protectors, and assisted the resident with their use. However, staff were unsure about the existence of physician orders for these devices. The nurse assigned to the resident and the unit manager both confirmed that physician orders should have been present, but were not found in the system until the unit manager entered them during the survey process. The Director of Nursing also confirmed that physician orders were required and that it was the responsibility of the admitting nurse and nurse management to ensure all necessary orders were obtained and documented. The facility's policy required that written and/or verbal orders for immediate care and needs, including treatment and routine care orders, be obtained upon admission to allow staff to provide essential care. The absence of physician orders for the back brace and foot protectors meant that staff did not have formal guidance for their use, which was inconsistent with professional standards of practice and the facility's own policies.
Failure to Administer Tube Feeding per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via feeding tube was administered the correct feeding rate as per physician orders. The resident, a male with a history of aphasia, stroke, hemiplegia, and severe cognitive impairment, was dependent on staff for eating and required tube feedings due to dysphagia. Physician orders specified a continuous feeding rate of 55 ml/hour, but observations and interviews revealed that the resident was instead receiving feedings at a rate of 60 ml/hour on multiple occasions. Family members and staff noted the discrepancy in the feeding rate, with the feeding pump and formula bag both indicating a rate of 60 ml/hour. Nursing staff, including an LVN, acknowledged administering the higher rate and stated that there was confusion regarding whether the physician order had been updated to reflect the new rate. However, the order in the system had not been updated, and the resident continued to receive feedings at the incorrect rate. The LVN and Unit Manager both confirmed that nurses were responsible for entering and updating physician orders, and that the Unit Manager was responsible for reviewing all orders for accuracy, but these processes were not followed in this case. The Director of Nursing (DON) confirmed that the resident was receiving a feeding rate inconsistent with the documented physician order and stated that nurses were responsible for following the orders as written. Facility policy required that feeding tubes be managed according to physician orders, including the specific rate and type of feeding, and that administration be periodically evaluated for consistency with those orders. The failure to administer the feeding at the prescribed rate constituted a deficiency in care for residents receiving enteral nutrition.
Failure to Obtain Physician Orders for Dialysis Care
Penalty
Summary
The facility failed to ensure that two residents requiring dialysis had appropriate physician orders for their dialysis treatments. Both residents had documented diagnoses of end-stage renal disease and were receiving dialysis, as reflected in their care plans and through staff interviews. However, a review of their electronic health records and physician orders for multiple months revealed that there were no orders for completing dialysis or for obtaining and documenting vital signs before and after dialysis sessions. Despite the care plans outlining specific interventions related to dialysis care, such as monitoring for complications, checking the access site, and encouraging attendance at scheduled dialysis appointments, these interventions were not supported by corresponding physician orders. Nursing staff and management interviews confirmed that the admitting nurse was responsible for entering these orders, but the orders were not present in the system. Staff were unaware of the missing orders until an audit was conducted, and both the unit manager and DON acknowledged the oversight. The facility's own hemodialysis policy required detailed physician orders for dialysis, including the type and location of access, dialysis schedule, nephrologist and facility contact information, transportation arrangements, and medication or fluid restrictions. The absence of these orders meant that staff relied on care plans and communication forms but lacked the formal physician directives necessary for consistent and safe dialysis care.
Failure to Administer and Secure Medications as Ordered
Penalty
Summary
A deficiency occurred when a nurse prepared morning medications for a resident with severe cognitive impairment and multiple diagnoses, including hypertension and hypothyroidism, but failed to administer them. The nurse placed the medication cup, containing a pink and a white pill, on the hallway handrail after being distracted by another resident attempting to get out of bed. The nurse did not return to retrieve or administer the medications to the intended resident. The missed medication was discovered later by another nurse, who found the cup labeled with the resident's room number on the hallway handrail. Upon review, it was confirmed that the resident had not received her prescribed doses of Levothyroxine and Liothyronine, which were ordered for her thyroid condition. The nurse who found the medication noted that he had not been informed of any missed doses and recognized the risk posed by the unattended medication. Interviews with facility staff, including the Unit Manager and DON, confirmed that the nurse responsible for the missed administration acknowledged the error. The nurse stated that he should have returned the medication to the cart before assisting the other resident but failed to do so. Facility policy requires that medications be administered according to the six rights of medication administration and that staff observe residents taking their medications, which was not followed in this instance.
Failure to Report Incident of Resident Self-Harm Attempt
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property, for one resident reviewed for abuse and neglect. Specifically, the facility did not report an incident in which a resident was found with a call light cord wrapped around his neck, an event that met the facility's definition of an adverse event and neglect. The facility's Abuse Prohibition Protocol required immediate reporting of such incidents to the State agency and other authorities within two hours, but this was not done. The resident involved was an older male with a history of anxiety disorder, cerebral infarction, and hemiplegia, and had moderate cognitive impairment. Prior to the incident, there was no documentation or indication of suicidal ideation or behaviors in his medical record or care plan. On the day of the incident, the resident was found agitated, refused care, and wrapped the call light cord around his neck, expressing suicidal statements. Staff responded by removing the cord, notifying medical providers, and placing the resident on one-on-one supervision until he was transported to the hospital for psychiatric evaluation. Assessments showed no physical harm or marks on the resident. Interviews with staff confirmed that the resident had not previously expressed suicidal ideation and that the incident was promptly managed in terms of resident safety and medical response. However, the Administrator, who was responsible for reporting such incidents, did not report the event to the State agency, as required by facility policy and regulation. The failure to report the incident constituted a violation of the facility's abuse prevention and reporting protocols.
Failure to Timely Report Alleged Neglect and Injury of Unknown Source
Penalty
Summary
The facility failed to ensure that all alleged violations involving neglect, including injuries of unknown source, were reported immediately, but no later than two hours after the allegation was made if the events involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events did not involve abuse and did not result in serious bodily injury. Specifically, the facility did not report an incident involving a resident who was found with a call light cord around his neck and expressing suicidal ideations. The event was not reported to the administrator and the State Survey Agency in accordance with state law and the facility's established procedures. The resident involved was an older male with a history of anxiety disorder, cerebral infarction, and hemiplegia, and had moderate cognitive impairment. Prior to the incident, there were no documented suicidal ideations or behaviors in his medical record, care plan, or hospital records. On the day of the incident, the resident was found agitated, refused care, and wrapped a call light cord around his neck while expressing a desire to die. Staff responded by removing the cord, clearing the room of potentially harmful items, and placing the resident on one-on-one supervision until he was transported to the hospital for psychiatric evaluation. No physical injuries were noted during the head-to-toe assessment. Interviews with staff confirmed that the incident was immediately addressed in terms of resident safety and medical response, but the required reporting to the State Survey Agency was not completed as per regulatory requirements. The administrator, DON, and other staff acknowledged that the administrator was responsible for reporting such incidents, and that the event was not reported because the administrator did not consider it reportable. The facility's current abuse prohibition protocol required all adverse events, including those with risk of serious injury, to be reported, but this protocol was not followed in this case.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency occurred when a nurse failed to treat a resident with dignity and respect. The incident involved a nurse raising her voice and scolding a resident who had repeatedly used her call light. Video evidence provided by the resident's family showed the nurse entering the resident's room, speaking in a stern tone, and reprimanding the resident for her actions. The nurse was heard saying, 'I've already helped you... now why are you doing this... you've got to stop this,' and continued to question the resident in a raised voice about her use of the call light and her behavior in bed. The resident involved was an elderly female with multiple diagnoses, including cancer, Alzheimer's disease, stroke, non-Alzheimer's dementia, seizure disorder, anxiety, depression, bipolar disorder, and schizophrenia. She had a severely impaired cognitive status, as indicated by a BIMS score of 3, and required extensive assistance with activities of daily living and transfers. The care plan reflected her need for substantial support, and staff interviews confirmed that she was alert and oriented but experienced moments of confusion and forgetfulness. The resident was known to press her call light repeatedly, sometimes without recalling the reason. Interviews with staff and the resident's family confirmed the incident, with the family noting that the nurse's behavior was 'very ugly' toward the resident. Staff members who worked with the resident stated that she had not reported mistreatment, and the resident herself did not recall the incident when interviewed. The facility's policy emphasized the right of residents to be free from abuse, neglect, and mistreatment, and the incident was documented as a failure to uphold these rights for the resident involved.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident who was on enhanced barrier precautions (EBP). Observations revealed that LVN A, CNA B, and CNA C did not wear gowns while providing direct care, including skin assessments and incontinence care, to a resident with a feeding tube and severe cognitive impairment. The resident's care plan and room signage clearly indicated the need for gown and glove use during all direct care activities, as required by the facility's EBP policy. However, staff were observed wearing only gloves, despite the presence of posted instructions and available PPE supplies. Interviews with the involved staff indicated gaps in knowledge and training regarding EBP requirements. CNA B was unaware that EBP required both gown and glove use and did not recall receiving training on the subject. CNA C believed gowns were only necessary for residents with catheters and did not recall seeing the EBP sign. LVN A admitted to forgetting to wear the gown despite knowing the policy. Review of training records confirmed that these staff members had not attended the facility's EBP training. The DON confirmed the policy and acknowledged uncertainty about staff training attendance, particularly for new employees.
Failure to Provide Written Notification for Hospital Transfer
Penalty
Summary
The facility failed to provide timely written notification to a resident and the resident's representative regarding a transfer to the hospital, including the reasons for the transfer and the right to appeal. Additionally, the facility did not send a copy of the notice to the Office of the State Long-Term Care Ombudsman. This deficiency was identified for one of the three residents reviewed for discharge notices. The resident in question, a male with intact cognition as indicated by a BIMS score of 15, was transferred to the hospital due to altered mental status and other health issues. Despite the transfer, there was no documentation showing that the resident or the Ombudsman were notified in writing about the transfer or the reasons for it. The resident later reported that he was not provided with any transfer or discharge paperwork from the facility, only receiving a 30-day discharge notice upon his return. Interviews with facility staff revealed a lack of awareness regarding the requirement to provide written notices for hospital transfers. The Unit Manager stated that residents and their representatives were notified verbally, and the Administrator admitted to being unaware of the need for written forms. The facility's policy on transfers and discharges, revised in October 2022, specifies that notices should be provided in a form and manner understandable to the resident, but this was not adhered to in this case.
Inadequate Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident requiring substantial assistance for transfers. A CNA attempted to transfer the resident using a mechanical lift without the required assistance from another staff member. During the transfer, the CNA left the resident suspended in the lift sling to seek help, leaving the resident unsupervised. This action was contrary to the facility's policy, which mandates that two staff members be present during mechanical lift transfers to ensure safety. The resident involved was a male with intact cognition, diagnosed with conditions including Type 2 diabetes, hypertension, and end-stage renal disease, requiring maximal assistance for transfers. Interviews with staff, including the CNA involved, confirmed that the procedure was not followed correctly, as two staff members are required to be present from the beginning to the end of the transfer process. The facility's policy and staff interviews highlighted the potential risks of leaving a resident unattended in a mechanical lift, such as falls or the lift tipping over, which could lead to injury.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by discrepancies in narcotic logs and the presence of expired medications. On two medication carts, the narcotic administration records did not match the actual pill counts for several residents. For instance, Resident #126's narcotic log showed 20 pills remaining, while the blister pack contained only 19 pills. Similarly, discrepancies were noted for Residents #8, #21, and #66, where the narcotic logs did not align with the physical counts of medications like hydrocodone, tramadol, and oxycodone. Interviews with the nursing staff revealed that the discrepancies were due to a failure to sign off on the narcotic administration records after administering medications. LVN G admitted to administering medications to Residents #8, #21, and #66 but forgot to document it, while LVN F also failed to log the administration of tramadol to Resident #126. Both nurses acknowledged the importance of logging medications immediately to prevent errors and discrepancies, yet these lapses occurred. Additionally, expired medications were found in the Central Supply cabinet, specifically two bottles of Vitamin A with an expiry date of April 2024. The responsibility for checking and removing expired medications was shared between the nursing staff and the Central Supply Staff, but interviews indicated a lack of consistent oversight. The ADON and DON acknowledged the importance of proper documentation and regular checks to prevent medication errors and potential drug diversion, but there was no evidence of recent training or audits to address these issues.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food during a lunch meal, as observed on 09/05/24. The planned menu included soft tacos, refried beans, shredded lettuce, diced tomato, grilled chicken, Brussels sprouts, mashed potatoes, and a brownie. During the observation, the pureed Brussels sprouts, mashed potatoes, and pureed beans were found to be without flavor, and the grilled chicken patty was colorless, bland, and flavorless. Despite these findings, the Regional Dietitian and Dietary Manager did not acknowledge any concerns with the taste of the food and reported not having received any complaints from staff about the bland taste. The Dietary Manager indicated that the cooks were responsible for the taste and presentation of the food. A confidential interview with thirteen alert and oriented residents revealed that food was typically served cold and lacked flavor, both in the dining room and on the halls, when state surveyors were not present. However, the resident council meeting minutes from June 2024 to September 2024 did not document any complaints about the food being cold or flavorless. The Dietitian and Dietary Manager also confirmed that they had not received any complaints regarding the food being cold or bland. The facility's policy on food storage emphasized keeping foods safe, wholesome, and appetizing, which was not adhered to in this instance.
Deficiencies in Food Storage and Ice Machine Cleanliness
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and the 300-hall nutrition room. In the kitchen, food items stored in the freezer were not properly labeled or dated after being removed from their original packaging. This included bags of breaded chicken patties, meatballs, French fries, and breaded fish. The Dietary Manager acknowledged that these items were leftovers from previous meals and should have been labeled with the name of the food item and the date they were opened. Additionally, a bag of ground meat in the refrigerator was found with a date of 08/11/24 but no end date, and the Dietary Manager could not confirm how long it had been stored. The facility's policy required food items to be covered, labeled, and dated, but this was not consistently followed. In the 300-hall nutrition room, the ice machine was found to have a white flap with a brown substance on it, which was in contact with the ice. The Maintenance Director stated that a contractor cleaned the ice machine about five months ago, and he last checked it a month ago without noticing the brown substance. The DON confirmed that staff were supposed to report any dirtiness in the ice machine to the Executive Director, Maintenance Director, and DON immediately. However, the maintenance logs from July 2024 did not reflect any cleaning needs for the ice machine. These lapses in food storage and equipment cleanliness could potentially place residents at risk for food contamination and foodborne illnesses.
Failure to Update Resident Care Plan with Current Diet Orders
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not reflect the current diet orders. The resident, a male with severe cognitive impairment and multiple diagnoses including vascular dementia and diabetes, had a diet order that was not updated in the care plan. The care plan inaccurately listed a mechanically altered diet, while the actual diet order was a regular diet with specific restrictions such as no salt, no orange juice, and no certain fruits and vegetables. This discrepancy was observed during a meal where the resident received a tray consistent with the current diet order, but the care plan had not been updated to reflect these changes. Interviews with facility staff, including an LVN, MDS Coordinator, ADON, and DON, revealed a lack of communication and responsibility in updating the care plan to match the diet orders. The LVN acknowledged the mismatch and noted it was the ADON's responsibility to update care plans. The MDS Coordinator admitted the oversight and emphasized the importance of matching diet orders with care plans to prevent errors, especially since the resident was on dialysis. The ADON and DON both highlighted the collaborative effort required to update care plans and the potential for confusion if discrepancies exist. The facility's policy mandates that care plans must match resident orders, but staff could not recall the last in-service training on this requirement.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for a resident, specifically in maintaining personal hygiene. Resident #290, an elderly male with diagnoses including hypertension, hyperlipidemia, non-Alzheimer's dementia, and edema, was observed in a disheveled state with greasy hair and unshaven facial hair. His bedding was soiled with dark amber and red stains, and he reported not having received a shower since the removal of a PICC line, despite expressing a desire for one. Interviews with staff revealed a lack of clarity and accountability regarding the resident's care. CNA A, who was not directly responsible for Resident #290, was unable to confirm when the resident last received a shower or bed bath, as there was no documentation of such care since his readmission. LVN B acknowledged the resident's unkempt appearance and soiled bedding, indicating that the resident had not been showered according to the facility's schedule. The DON confirmed that CNAs were responsible for offering showers upon admission and maintaining a regular schedule, but there was no documentation of the resident refusing care. The facility's policy on activities of daily living emphasized consistent assignments and documentation, yet these were not adhered to in Resident #290's case. The lack of proper hygiene care placed the resident at risk of infection, particularly given his recent clearance from isolation for a urinary tract infection and COVID. The failure to provide scheduled showers and maintain hygiene documentation highlights a deficiency in the facility's care practices.
Failure to Label IV Medication Bags and Tubing
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, as observed during a survey. The deficiency involved a resident who was receiving IV medication through a peripherally inserted central catheter (PICC) line. The IV medication bag and tubing were not labeled with the date, time, and initials of the administering nurse, which is a requirement to ensure proper medication administration and prevent errors. This oversight was noted during an observation of the resident in her room, where an unlabeled IV bag and tubing were found hanging on the pole. Interviews with the licensed vocational nurse (LVN) responsible for administering the IV medication revealed that she was aware of the requirement to label the IV bag and tubing but failed to do so. The LVN acknowledged that not labeling the bag and tubing could lead to medication errors, such as overdose or omission of a dose, and infection control issues. The Director of Nursing (DON) confirmed the expectation for staff to label and initial IV bags and tubing to prevent such errors. Despite previous training on IV administration, the facility's policy on labeling IV equipment was not followed, leading to this deficiency.
Inaccurate Documentation of Catheter Care
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of catheter care. The resident, a female with a BIMS score indicating no cognitive impairment, had an indwelling catheter that was ordered to be discontinued. However, progress notes inaccurately documented the presence of a catheter on multiple occasions after it was supposed to be removed. Observations and interviews confirmed that the resident did not have a catheter in place at the time of the survey. Interviews with staff, including an LVN and the DON, revealed discrepancies in the documentation process. The LVN confirmed that no catheter care was being provided, and the DON emphasized the importance of accurate documentation. The facility's policy on charting and documentation requires that records be objective, complete, and accurate, which was not adhered to in this case. This failure could lead to miscommunication regarding the resident's care.
Resident's Right to Choose Pain Management Provider Not Honored
Penalty
Summary
The facility failed to honor a resident's right to choose his pain management provider, which is a violation of resident rights. The resident, a male with multiple medical conditions including chronic pain syndrome and opioid dependence, expressed dissatisfaction with the facility's contracted pain management nurse practitioner (NP). Despite his intact cognition and frequent complaints of pain, the resident was not allowed to change his pain management provider after expressing concerns about his current regimen and the NP's approach. The resident reported to a licensed vocational nurse (LVN) that he wanted a new pain management doctor, but was told that facility policy required him to use the contracted provider or leave the facility. The resident was afraid to formally dismiss the NP due to concerns about continuing his pain medication regimen. The facility's staff, including the administrator and interim director of nursing (DON), were aware of the resident's dissatisfaction but did not take timely action to address his request for a new provider. The social worker (SW) only became aware of the issue when the resident threatened to call the state agency. Interviews with facility staff revealed a lack of communication and follow-up on the resident's request. The LVN reported the resident's concerns during a morning meeting, but it was unclear if management took any action. The interim DON acknowledged the resident's dissatisfaction but did not speak to him directly. The administrator admitted to not discussing the resident's rights with him, which contributed to the deficiency in ensuring the resident's right to self-determination and access to preferred medical services.
Resident Left Unsupervised in Extreme Heat
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, leading to severe consequences. The resident, who had a history of vascular dementia, hemiplegia, and other medical conditions, was left unsupervised in 96-degree heat for approximately two hours. This resulted in the resident becoming unresponsive, suffering second-degree skin burns, and experiencing heat stroke, which required hospitalization. The care plan for the resident did not adequately address the resident's behavior of wanting to sit outside in the courtyard, especially during extreme weather conditions. Although the resident was cautioned about the heat and offered water, the staff did not ensure the resident's safety by supervising or documenting interventions when the resident refused hydration and to come inside. The lack of supervision and failure to implement the care plan interventions led to the resident's critical condition. Interviews with staff and other residents revealed that the resident was found unresponsive in a wheelchair on the patio. Despite being warned about the heat, the resident was left outside without proper monitoring. The facility's investigation indicated that there was no documentation of staff checking on the resident or implementing behavior interventions, highlighting a significant oversight in ensuring the resident's safety and well-being.
Resident Left Unattended in Extreme Heat Resulting in Hospitalization
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was left unattended in 96-degree heat for approximately two hours. This resulted in the resident becoming unresponsive, suffering second-degree skin burns, and experiencing heat stroke, which required hospitalization. The resident, who had a history of vascular dementia, hemiplegia, and other medical conditions, was known to enjoy sitting outside and was assisted to the patio by a CNA. Despite being cautioned about the heat and offered water, the resident was left unsupervised. The resident's care plan indicated a need for total dependence on staff for transfers and supervision during ambulation. However, there was no documentation that staff intervened to ensure the resident's safety or offered hydration while he was outside. The facility's investigation revealed that the resident was found unresponsive in his wheelchair on the patio by another resident, who alerted a nurse. The nurse brought the resident inside and attempted to cool him down with ice and wet towels before calling 911. Interviews with staff and residents indicated that the resident often refused to come inside despite the heat, and there was a lack of documentation regarding staff checks or interventions. The facility's policies on care plans and documentation were not followed, as there was no record of staff monitoring the resident's condition or behavior while outside. The incident highlighted a failure in supervision and adherence to care plans, which placed the resident at risk of harm.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as required by professional principles, which led to a deficiency in medication storage practices. During an observation, it was noted that a Licensed Vocational Nurse (LVN) left a resident's morning intravenous (IV) and injection medications unattended on top of a medication cart in the hallway. The cart was parked outside the resident's room, with the lock in the open position, allowing unauthorized access to the medications. This lapse in protocol was observed when the LVN was inside the resident's room, unable to see the medications from her position, and the medications were visible to anyone passing by. The resident involved had a history of cellulitis, type 2 diabetes with diabetic polyneuropathy, and chronic arterial fibrillation, requiring insulin injections and IV antibiotics. The facility's Director of Nursing (DON) and Executive Director (ED) both acknowledged that the facility's policy required medications to be secured in locked carts at all times to prevent unauthorized access and potential adverse reactions. Despite the facility's policy and previous in-service training on medication security, the LVN admitted to not securing the medications properly, which was a breach of the facility's medication security policy.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. Specifically, the 600 Hall Medication Cart was left unlocked and unattended by LVN C, who was assisting a resident in their room. This oversight was observed when the medication cart was parked outside the resident's room, with no staff present in the hallway, allowing two residents to walk past the unsecured cart. LVN C acknowledged the mistake, stating that the cart should have been locked to prevent unauthorized access to medications. Interviews with the Director of Nursing (DON) and the Executive Director (ED) confirmed that the facility's policy required medication carts to be locked at all times to prevent residents from accessing medications not prescribed to them, which could lead to adverse reactions. Despite the facility's policy on medication security, the Executive Director was unable to provide a copy of this policy when requested during the survey. The facility's policy on medication administration, dated November 2017, was reviewed, but it did not specifically address the security of medication carts.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with cognitive impairment and an unsteady gait. The resident, who had a history of attempting to get up from her wheelchair unassisted, was left alone in her room by a hospice aide and subsequently fell, sustaining multiple lacerations and a wrist injury that required hospital treatment. The resident was known to be a high fall risk and had specific care plan interventions, including being kept near the nurse's station for closer monitoring, which were not followed at the time of the incident. Interviews with facility staff revealed that the hospice aide, who was aware of the resident's fall risk, left the resident unattended in her room after providing care. The LVN on duty was on a break and not present to ensure the resident was returned to a monitored area. The CNA who discovered the resident on the floor confirmed that the resident had a red bracelet indicating a high fall risk and should have been monitored more closely. The facility's policy on fall management was not adhered to, as the resident was not adequately supervised. The Director of Nursing (DON) and other staff members acknowledged the resident's high fall risk and the need for frequent monitoring. Despite this, the resident was left alone, leading to the fall and subsequent injuries. The facility's failure to implement the care plan and ensure proper supervision directly contributed to the incident, highlighting a significant lapse in the standard of care provided to the resident.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
