The Lev At Town Park
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 8820 Town Park Dr, Houston, Texas 77036
- CMS Provider Number
- 455800
- Inspections on file
- 30
- Latest survey
- November 17, 2025
- Citations (last 12 mo.)
- 2 (2 serious)
Citation history
Health deficiencies cited at The Lev At Town Park during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of stroke experienced significant knee pain and swelling, which staff failed to promptly assess, document, or report to the physician. Despite severe pain and a later x-ray revealing a femoral fracture, there were delays in both medical notification and hospital transfer, resulting in prolonged pain and delayed emergency surgery.
A resident with severe cognitive impairment and a history of stroke experienced escalating pain and swelling in the left knee, which was not promptly assessed or reported by nursing staff. Despite repeated complaints and a family member's concerns, staff delayed in notifying the physician and obtaining diagnostic imaging. After an x-ray revealed a displaced femoral fracture, there was a further delay of approximately 13 hours before the resident was sent to the hospital for emergency surgery, with inadequate pain management and monitoring throughout the incident.
A medication aide left a computer unlocked and unattended, displaying multiple residents' photos and names, making confidential medical information accessible. The aide admitted to forgetting to lock the computer and acknowledged this as a privacy violation, despite having received prior training on protecting resident records. The facility's policy requires all personal and medical records to be kept secure and confidential, and the administrator confirmed that staff must always protect resident information.
Three residents did not have comprehensive care plans addressing their specific needs, including exit-seeking behavior, use of oxygen and anticoagulants, and DNR status. Staff and documentation confirmed that these care plans were missing despite clear evidence of the residents' conditions and physician orders.
A resident with cognitive impairment and physical limitations was not provided timely assistance with the removal of unwanted facial hair, despite expressing a desire for this care and being unable to perform it independently. Staff interviews and observations confirmed that grooming assistance was not consistently provided as required by the resident's care plan and facility policy, resulting in the resident feeling unclean.
Multiple staff members failed to follow infection control protocols, including improper handling of linens and care items, lack of PPE use during direct care for residents on Enhanced Barrier Precautions, and missing infection control signage. These actions involved two residents with significant medical needs and resulted in increased risk of cross-contamination and infection.
Surveyors found expired medications on two medication carts, including Tramadol, Hyoscyamine Sulfate, and Haloperidol, which were not removed despite facility policies and recent in-services on medication management. Nursing staff acknowledged missing the expired medications during routine checks, and records showed that the affected residents had not received these medications in recent months.
A CNA placed a resident's Foley catheter drainage bag on the bed during catheter care, instead of keeping it below bladder level as required by facility policy and infection control standards. This action was observed and acknowledged by staff as improper, given the resident's medical history and care plan directives.
A nurse failed to verify the placement of a gastrostomy tube before administering medications to a resident with severe cognitive impairment and multiple medical conditions. Instead of following facility policy to confirm tube placement, the nurse only checked for residual contents and proceeded with medication administration. Staff interviews revealed inconsistent practices and understanding of proper tube placement verification, which did not align with facility policy.
A resident with moderate cognitive impairment and significant care needs was unable to summon staff assistance due to a non-functional call light system. The issue was discovered when the resident reported unanswered calls and the call light failed to activate during testing. Staff later found the cords unplugged, and the system only worked after being re-inserted, indicating a lapse in monitoring and ensuring call light functionality.
A resident with a history of yelling, cursing, and verbal abuse toward staff and family members was not accurately coded for behavioral symptoms on the quarterly MDS. Despite multiple nurse's notes and staff interviews documenting these behaviors, the staff member completing the MDS did not review available documentation or consult with other staff, leading to an incomplete assessment.
The facility had an 18% medication error rate, involving three residents who did not receive their medications as prescribed. Errors included administering medications without food, incorrect dosage measurement, and not following medication label instructions. Staff failed to adhere to proper medication administration procedures despite training.
The facility failed to maintain proper temperatures for leftover breakfast food and to safely thaw frozen food, placing residents at risk of foodborne illness. Scrambled eggs and hard-boiled eggs were stored at unsafe temperatures, and frozen pork was thawed in stagnant water at temperatures above the recommended level.
The facility failed to maintain an effective infection control program, as evidenced by a CNA not performing hand hygiene between glove changes during incontinent care and an LVN not maintaining sterile technique during tracheostomy care. These deficiencies were observed during direct care activities and confirmed through staff interviews.
A facility failed to ensure proper catheter care and hand hygiene for a resident with multiple medical conditions, including a history of UTIs. CNA A did not follow correct procedures for cleaning the Foley catheter and hand hygiene, which was acknowledged by the CNA and confirmed by the DON. The resident had recently been hospitalized for a UTI, and the facility lacked a documented policy for incontinent and Foley catheter care.
A facility failed to provide proper respiratory care for a resident with a tracheostomy, including not using sterile techniques during suctioning and not maintaining the prescribed oxygen levels. The resident, who has multiple medical conditions, was observed with moist breath sounds and foam at the mouth, indicating potential respiratory distress. The LVN admitted to not following proper procedures, and the DON acknowledged the need for updated training.
A facility failed to ensure accurate medication administration when a medication aide administered Minocycline along with a multi-vitamin and iron tablet to a resident, despite warnings against such combinations. The resident, who had multiple diagnoses and intact cognition, complained about the number of medications. The aide admitted to not reading the medication label, and the DON and Administrator emphasized the importance of following physician orders.
A resident with a complex medical history was allegedly slapped by a CNA during a night shift, leading to feelings of unsafety and distress. The incident was reported, and the CNA was terminated following an investigation. The resident had moderate cognitive impairment but was able to communicate her needs and had previously reported issues to the administration.
A resident's right to privacy and dignity was compromised when a CNA entered their room without knocking. Despite being trained on resident rights, the CNA failed to adhere to the protocol of knocking and introducing themselves. The resident, who was cognitively intact, reported frequent occurrences of staff entering without knocking. The facility's policy emphasizes maintaining resident dignity and privacy, which includes knocking before entering a room.
Two residents with severe cognitive impairment were left soiled and unattended, failing to receive necessary incontinence care. A CNA admitted to not changing the residents before leaving the shift, and the facility's policies on resident dignity and neglect were not followed. The incident was reported to the Administrator, highlighting a lapse in care for residents dependent on staff for daily living activities.
A resident in an LTC facility was found using a space heater in his room, despite knowing it was against policy due to fire safety concerns. The resident, who felt cold due to heat intolerance, repeatedly acquired space heaters, which were removed by staff only for him to replace them. The Maintenance Director, responsible for temperature adjustments and safety checks, was unaware of the heater's presence during his rounds, indicating a lapse in monitoring and enforcement of safety policies.
Failure to Immediately Notify Physician and Act on Change in Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify appropriate parties when there was a significant change in the resident's condition. The resident, who had severe cognitive impairment, non-Alzheimer's dementia, a history of stroke, and was dependent on staff for all activities of daily living, began experiencing pain and swelling in the left knee. Despite complaints of pain and visible swelling, nursing staff did not promptly assess, document, or notify the physician or nurse practitioner of the change in condition. Pain assessments and administration of PRN pain medications were delayed, and there was a lack of timely documentation and follow-up regarding the resident's ongoing pain and swelling. On multiple occasions, the resident reported severe pain (rated 8 out of 10) and swelling in the knee, but staff failed to immediately notify the physician or seek medical guidance. The resident's family member also reported the pain and swelling to staff, but the response was inadequate, with staff either not documenting the incident or not escalating the issue appropriately. When an x-ray was eventually ordered and revealed a displaced distal femoral shaft spiral fracture, there was a significant delay—approximately 13 hours—before the resident was transported to the hospital for emergency surgery. During this period, the resident continued to experience severe pain without appropriate intervention or escalation. Interviews with staff and review of records confirmed that there were lapses in assessment, documentation, and communication regarding the resident's change in condition. Staff failed to recognize the significance of the resident's symptoms, did not follow the facility's policy for notification of changes, and did not act promptly on critical diagnostic information. The delay in seeking medical attention and transporting the resident to the hospital after the fracture was identified resulted in prolonged pain and delayed treatment for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) are to be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers.
- Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- Charge Nurses, CNA's and Med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- Monitoring began including review of all in-service sign-in sheets and staff interviews to validate understanding and compliance.
Delayed Response to Acute Fracture and Change in Condition
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, non-Alzheimer's dementia, and a history of stroke did not receive timely and appropriate care following a significant change in condition. The resident, who was bedbound and dependent on staff for all activities of daily living, began experiencing severe pain and swelling in the left knee. Despite multiple complaints of pain from the resident and reports from family members, nursing staff failed to conduct thorough assessments, document findings, or notify the physician or nurse practitioner promptly. Pain assessments were inconsistently performed, and there was a lack of documentation regarding the resident's pain and condition changes during several shifts. When the resident's pain escalated and was unrelieved by PRN pain medications, staff delayed in escalating care and obtaining necessary diagnostic imaging. An x-ray was eventually ordered and performed, revealing a displaced distal femoral shaft spiral fracture. However, after the facility received the x-ray results indicating an acute fracture, there was a delay of approximately 13 hours before the resident was transported to the hospital for emergency evaluation and surgery. During this period, staff did not immediately notify the physician or nurse practitioner, nor did they reassess or adequately monitor the resident's condition. Interviews with staff and family confirmed that the resident's pain was not effectively managed, and communication breakdowns occurred at multiple points, including failure to document assessments, notify appropriate clinical leadership, and act on critical diagnostic findings. The facility's own Director of Nursing acknowledged that the change in condition should have been recognized and acted upon much earlier, and that the delay in care could have resulted in continued pain and adverse outcomes for the resident.
Removal Plan
- DON and Unit Manager provided education to Charge nurses to immediately assess residents with a reported change of condition.
- Charge nurses, CNA's and Med Aides were educated that pain is a clinical change that requires immediate assessment and timely physician notification.
- Charge nurses were instructed to conduct and document a Pain Assessment.
- Notify the PCP immediately when a resident exhibits new or worsening pain or when it contributes to a suspected change in condition.
- DON or designee (Unit Manager or Administrator) will be notified of a change in condition.
- Implement and document physician orders in PCC.
- Reassess pain within one hour of pain medication and document effectiveness, if applicable.
- Change of Condition E-Interact UDA in PCC will be completed upon determination a change in condition has occurred.
- Residents with a change of condition will be noted on the 24-hour report for oncoming shifts.
- DON or designee will review the 24-hour report and nurses' notes daily to ensure: Change of conditions identified, Pain Assessments were completed, The PCP was notified when pain or other symptoms indicated a change in condition, and Orders were implemented and followed.
- Charge nurses were educated when receiving new x-ray results, they are to: Notify the practitioner immediately, Notify DON or designee (Unit Manager or Administrator), Document notification in PCC, Enter any new orders in PCC, If the PCP cannot be reached and results indicate a fracture, the resident is to be sent out to the ER immediately for emergency evaluation.
- Charge nurses were further instructed that pain associated with suspected fractures, injuries, or clinical decline must be reported immediately to the PCP and should not wait for the next shift or routine rounding.
- All residents were assessed for a change of condition, including assessment for new or worsening pain, by the DON and Unit Managers. Any noted changes of condition - including pain related changes - will be reported to the PCP immediately, Change of Condition E-Interact UDA will be completed in PCC, 24 Hour report will be updated and family notified.
- The facility will provide education regarding reporting recognition of change of condition, including pain, and immediate reporting to the PCP to all licensed nurses upon hire, as well as ongoing on a monthly basis for a minimum of 6 months.
- This education includes: Completing and documenting Pain Assessments, Notifying the PCP promptly for any unrelieved, new or worsening pain, Documenting PRN pain medication response, Understanding when pain represents a significant change in condition.
- Charge Nurses, CNA's and med Aides will be required to have training on change of condition and proper reporting, including pain recognition and escalation, prior to assuming resident care responsibilities and will not be allowed to work their next scheduled shift until training is completed.
- The process outlined above was reviewed by the Director of Nursing, Nursing Home Administrator and Medical Director during an Ad Hoc QAPI meeting.
- The Administrator will be responsible for monitoring the above actions for compliance which will be an ongoing process.
- The Administrator will ensure the plan is completed in full.
- Charge Nurses, CNA's and Med Aides will not be allowed to work next shift without in-service.
- All In-service sign-in sheets were requested and reviewed.
- Interviews were conducted on all shifts with staff to verify the in-services and competencies had been conducted and to validate the staff understanding of the information presented to them.
Unattended Computer Exposes Resident Medical Records
Penalty
Summary
A medication aide (MA) left her computer unattended and unlocked, displaying multiple resident profiles with photos and names visible on the screen. This occurred when the MA stepped away from her medication cart to check for a medication in the medication room, leaving the computer accessible and exposing confidential resident information. The MA acknowledged during an interview that she had forgotten to lock the computer and recognized this as a violation of privacy and confidentiality policies, as well as a potential HIPAA violation. She also confirmed that she had previously received in-service training on protecting resident medical records. The facility's policy on confidentiality, reviewed as part of the investigation, states that all personal and medical records must be kept secure and confidential, regardless of the form or location of storage. The administrator confirmed in an interview that staff are required to always protect resident medical records, and failure to do so places residents at risk of having their privacy invaded. The incident was observed and confirmed through interviews and record review, demonstrating a failure to safeguard resident information as required by facility policy.
Failure to Develop and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans to address the medical, mental, and psychosocial needs of three residents. One resident, with diagnoses including schizophrenia and moderate cognitive impairment, exhibited repeated behaviors of pushing on the exit door near her room, as documented in progress notes on multiple occasions. Despite these documented behaviors and staff awareness, there was no care plan in place to address her exit-seeking or wandering behavior until after surveyor intervention. Staff interviews confirmed that the behavior was not initially care-planned, and the resident was only redirected when she attempted to push on the door. Another resident, who had moderate cognitive impairment and required substantial assistance with activities of daily living, was prescribed both oxygen and anticoagulant therapy. However, there were no care plans with interventions to address the use of oxygen or anticoagulants, despite physician orders for both. Staff interviews, including those with the MDS coordinator and DON, confirmed the absence of these care plans and acknowledged that such omissions could result in resident needs not being addressed. A third resident, with advanced directives indicating Do Not Resuscitate (DNR) status, also lacked a care plan to address this directive. Although the resident's DNR status was documented in physician orders and on the DNR form, the care plan did not reflect this critical information. Staff interviews confirmed that the care plan should have included the DNR status to ensure the resident's wishes were respected. The facility's own policies require that care plans include measurable objectives and interventions for all identified needs, but these were not followed for the residents in question.
Failure to Provide Timely Assistance with Grooming and Personal Hygiene
Penalty
Summary
A deficiency was identified when a resident with Alzheimer's disease, Parkinson's disease, muscle weakness, and dementia, who required assistance with personal care and supervision for personal hygiene, was observed to have a moderate amount of unwanted facial hair on her chin and above her top lip. The resident expressed that she was unable to remove the facial hair herself due to hand tremors and stated she would like the hair removed. Multiple observations confirmed the presence of facial hair over several days, and the resident reported not knowing when it was last removed by staff. Interviews with staff, including the DON and a CNA, confirmed that it was the responsibility of CNAs and nurses to ensure residents were groomed, including the removal of unwanted facial hair. The facility's policy emphasized the importance of maintaining resident dignity and grooming according to resident preference. Despite these policies and the resident's care plan, the necessary assistance with grooming was not provided in a timely manner, resulting in the resident feeling unclean and expressing a desire for improved personal hygiene.
Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed breaches in infection control practices involving two residents and several staff members. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) were observed handling potentially contaminated items inappropriately, such as placing a used sheet back on a clean linen cart after providing incontinent care, and carrying used disposable wipes from a resident's room to a medication cart. Additionally, resident care items like wash basins and urinals were found unlabeled, unbagged, and improperly stored in resident bathrooms, contrary to infection control protocols. Staff members providing care to residents on Enhanced Barrier Precautions (EBP), including those with indwelling Foley catheters and feeding tubes, did not consistently wear the required personal protective equipment (PPE), such as disposable gowns and gloves. Observations revealed that EBP signage was missing from the doors of residents who required these precautions, and several staff members, including CNAs and LVNs, were unfamiliar with EBP protocols. The care plans for the affected residents did not include EBP measures, despite physician orders and diagnoses indicating the need for such precautions. Interviews with staff and review of facility policies confirmed a lack of understanding and inconsistent implementation of infection control and EBP protocols. Staff members admitted to not following proper procedures for labeling, bagging, and storing resident care items, and for donning appropriate PPE when providing direct care to residents with wounds, indwelling devices, or artificial openings. These failures were directly observed and acknowledged by staff, placing residents at risk for cross-contamination and infection.
Expired Medications Not Removed from Medication Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the timely removal of expired medications from two medication carts. On Med Cart A, three blister packs of Tramadol 50 mg tablets, totaling 68 tablets and all with the same expiration date, were found. The nurse responsible for the cart acknowledged missing the expired medication during routine checks. The medication administration records showed that the resident had not received Tramadol for several months, and the medication had not been administered during the period in question, despite the presence of a new order. On Med Cart B, a blister pack containing nine tablets of Hyoscyamine Sulfate and another containing one tablet of Haloperidol, both expired, were found. The nurse interviewed stated that nurses and unit managers were supposed to check the carts weekly, but the expired medications remained. The medications were associated with a resident who had not received them in recent months, and one of the medications had been discontinued without a documented end date. The nurse indicated that the medications had come from the resident's hospice and were no longer in use. Interviews with nursing staff and facility leadership confirmed that procedures were in place for checking medication expiration dates, and recent in-services had been conducted on medication management. However, the expired medications were not identified or removed as required by facility policy, which states that expired medications should be reported to the nurse manager. The failure to remove expired medications from the carts was observed directly by surveyors during their review.
Improper Foley Catheter Bag Placement During Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) provided Foley catheter care to a female resident with a history of urinary tract infection, dementia, acute kidney failure, severe sepsis, and neuralgia. The resident had an indwelling Foley catheter as documented in her medical records and care plan, which specified that the catheter drainage bag should be kept below the level of the bladder to prevent backflow of urine. During the observed catheter care, the CNA removed the Foley bag from its proper position and placed it on the resident's bed, contrary to facility policy and standard infection control practices. The CNA later acknowledged awareness of the correct procedure and admitted that placing the Foley bag on the bed could result in urine backflow, increasing the risk of urinary tract infection. The facility's Infection Control Preventionist confirmed that the Foley bag should always remain below the bladder during care. Facility policies reviewed also emphasized the importance of maintaining the drainage bag below bladder level to discourage backflow and ensure quality of care in accordance with professional standards.
Failure to Verify G-Tube Placement Prior to Medication Administration
Penalty
Summary
A deficiency occurred when a nurse failed to verify gastrostomy tube placement prior to administering medications to a resident with a feeding tube, as required by facility policy. The nurse entered the resident's room to administer medications via the G-tube but did not check for tube placement or observe the tube site before proceeding. Instead, the nurse checked for residual contents and, finding none, flushed the tube and administered the medications, followed by another flush. The nurse did not use a stethoscope or other approved method to confirm tube placement, which was inconsistent with the facility's written procedures. The resident involved was an elderly female with severe cognitive impairment, dysphagia, protein calorie malnutrition, cerebral infarction, Alzheimer's disease, gastro-esophageal reflux disease, and a history of adult failure to thrive. She was receiving continuous enteral nutrition and had physician orders for specific medications to be administered via the G-tube. The care plan for this resident included monitoring for signs and symptoms of aspiration, infection, and tube dysfunction, and the facility's policies required verification of tube placement before administering any fluids or medications. Interviews with nursing staff and the DON revealed inconsistent understanding and practices regarding tube placement verification. One nurse stated she was told by the DON that checking for residual was sufficient, while another nurse described using both residual checks and a stethoscope. The DON referenced a change in procedure but could not provide clear guidance consistent with written policy, which specified checking tube length, retention device position, and, if available, pH measurement. This failure to follow established protocols placed the resident at risk for complications associated with improper tube placement.
Non-Functional Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system was found to be non-functional, preventing the resident from being able to summon staff assistance. The resident, a male with a history of lobar pneumonia and Parkinson's Disease, had moderate cognitive impairment and required significant assistance with activities of daily living, including transfers and continence care. During an observation, the resident reported that his call light had not been answered for the past week. When tested, the call light failed to activate the indicator outside the room, confirming it was not working. The call light cords for both beds were found unplugged and only worked after being re-inserted. Staff interviews revealed that the call light system is considered essential for resident safety and communication of needs. The facility's policy requires that call lights be accessible and functional in all resident areas, including bathrooms and bathing facilities, and that all staff are responsible for monitoring and reporting any issues. Despite these policies, the non-functional call light was not identified or addressed in a timely manner, resulting in the resident being unable to reliably call for assistance.
Failure to Accurately Assess and Code Resident Behaviors on MDS
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected his behavioral status. The quarterly Minimum Data Set (MDS) for the resident did not code for any behavioral symptoms, such as yelling, cursing, or verbal abuse, despite multiple documented incidents in the nurse's notes. These notes described repeated episodes where the resident shouted profanities, was verbally abusive toward staff and family members, and exhibited resistance to care. The care plan also identified the resident as being resistive to care and refusing care at times. Interviews with various staff members, including social workers, nurses, and CNAs, confirmed that the resident frequently displayed behaviors such as yelling, cursing, and making delusional statements about animals in his room. Staff consistently reported these behaviors, and the documentation in the nurse's notes supported their accounts. However, the staff member responsible for completing the MDS did not observe these behaviors during her assessment and did not review the nurse's notes or consult with other staff before coding the MDS. The facility's policy requires that all disciplines follow the guidelines in the RAI Manual and use a comprehensive assessment process, including reviewing nurse's notes and CNA documentation. The failure to accurately code the resident's behaviors on the MDS was due to the assessor not consulting available documentation or other staff, resulting in an incomplete and inaccurate assessment of the resident's behavioral needs.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in an 18% error rate based on 6 errors out of 32 opportunities. This involved three residents who did not receive their medications as prescribed. One resident did not receive Metoprolol and Metformin as ordered by the physician, as the medications were administered without food, contrary to the instructions. The resident confirmed that she had not eaten, and the facility's posted menu indicated that dinner was served later than the medication administration time. The medication aide incorrectly stated that the resident had snacks before the medication was given. Another resident received an incorrect dosage of Levetiracetam due to the medication aide's failure to accurately measure the liquid medication. The aide admitted to not placing the medication cup on a flat surface and misreading the calibrated line on the cup. Despite having received training on medication administration, the aide did not follow the correct procedure, leading to the administration error. A third resident was given Minocycline along with a multi-vitamin and iron tablet, despite the medication label indicating that these should not be taken together. The medication aide was unaware of this instruction and did not read the label before administering the medications. The Director of Nursing and the Administrator both emphasized the importance of following physician orders and reading medication labels, but the facility's policy on medication administration was not provided during the survey.
Improper Food Storage and Thawing Procedures
Penalty
Summary
The facility failed to maintain proper temperature for leftover food from the breakfast tray line serving cart and to ensure frozen food was safely thawed. During an observation, it was noted that scrambled eggs stored in the refrigerator since 8:00 AM had a temperature of 72 degrees Fahrenheit, and hard-boiled eggs had a temperature of 49.2 degrees Fahrenheit. These temperatures are within the 'danger zone' where bacteria and other foodborne pathogens can grow quickly. The Dietary Food Service Manager acknowledged the importance of maintaining proper food temperatures for resident safety and wellness. Additionally, an observation of the facility kitchen revealed that frozen pork chops and cubed pork were immersed in stagnant water in the sink, with temperatures ranging from 48 to 69.1 degrees Fahrenheit. The water temperature was 75.6 degrees Fahrenheit, which is above the recommended temperature for safe thawing. The facility's policies and procedures for cooling and heating foods, as well as food preparation and handling, were not followed, leading to these deficiencies.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff and residents. In the first incident, a CNA did not perform hand hygiene between glove changes while providing incontinent care for a resident with multiple medical conditions, including severe cognitive impairment and bowel incontinence. The CNA admitted to forgetting to wash hands or use hand sanitizer, despite knowing the importance of this practice to prevent reinfection. The Director of Nursing (DON) confirmed that staff are required to wash hands or use hand sanitizer with each glove change and acknowledged the need for improved skill checks and training. In the second incident, an LVN failed to maintain sterile technique while providing tracheostomy care to a resident with cerebral palsy, tracheostomy status, and other significant medical conditions. The LVN did not wash hands or use hand sanitizer during the procedure and used non-sterile techniques, such as handling sterile equipment with unwashed hands and reusing gloves. The LVN admitted to not following proper sterile procedures and acknowledged the potential risks of infection. The DON noted that the last in-service training on tracheostomy care was several months prior and recognized the need for updated training. These deficiencies were observed during direct care activities and confirmed through interviews with the involved staff and the DON. The lack of adherence to proper infection control practices by the CNA and LVN could place residents at risk for the spread of infection and cross-contamination. The facility's infection control program was found to be inadequate in ensuring a safe and sanitary environment for residents.
Improper Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling Foley catheter, leading to potential infection risks. During an observation, CNA A did not follow proper hand hygiene and catheter cleaning procedures. Specifically, CNA A did not open the labia to clean, did not clean the catheter tubing in a circular motion, and changed gloves multiple times without washing hands or using hand sanitizer. This improper technique was acknowledged by CNA A, who admitted to forgetting the correct procedure despite receiving monthly training on incontinent care and hand washing. The Director of Nursing (DON) confirmed the correct procedure and acknowledged the risk of infection due to deviations from the policy, although no specific policy for incontinent and Foley catheter care was provided during the interview. The resident involved, an elderly individual with multiple medical diagnoses including Type 2 diabetes, dementia, and neuromuscular dysfunction of the bladder, had a history of urinary tract infections (UTIs). The resident had recently been hospitalized for a UTI and had completed a course of intravenous antibiotics. The failure to follow proper catheter care and hand hygiene protocols could have contributed to the resident's recurrent infections. The DON and Administrator both emphasized the importance of proper incontinent care and hand washing to prevent infections, but the facility lacked a documented policy for these procedures.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, including tracheotomy care and tracheal suctioning, received such care consistent with professional standards of practice and the resident's care plan. Specifically, LVN A did not use sterile technique during tracheotomy suctioning for a resident, which is a critical aspect of preventing infections. The resident's oxygen was also not set per physician orders, as observed on multiple occasions where the oxygen concentrator read 3.5L/min instead of the prescribed 4-6L/min. The resident, a male with multiple medical diagnoses including cerebral palsy, tracheostomy status, and epilepsy, was observed in bed with moist breath sounds and foam coming out of his mouth, indicating potential respiratory distress. LVN A performed tracheotomy care without adhering to sterile procedures, such as not washing hands or using hand sanitizer between glove changes and using non-sterile gloves to handle sterile equipment. This improper technique was acknowledged by LVN A during an interview, where she admitted to not following the correct procedures and recognized the risk of infection. The Director of Nursing (DON) confirmed that the last in-service training on tracheostomy care was conducted in September 2023 and acknowledged the need for updated training. The DON also mentioned that the facility had recently changed companies for respiratory therapy services and was in the process of arranging new in-service training. The failure to follow sterile techniques and maintain the prescribed oxygen levels placed the resident at risk for respiratory infections and other complications.
Failure to Ensure Accurate Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate administration of medications for one resident reviewed for medication administration. Specifically, a medication aide (MA C) administered Minocycline along with a daily multi-vitamin and iron tablet to a resident, despite the medication label warning against taking Minocycline with vitamins or iron within two hours. This error was observed during a medication administration session, where the resident complained about taking too many medications at once. MA C admitted to not being aware of the specific warning and did not read the medication label, despite having received in-service training and being monitored during medication passes. The resident involved was a male with multiple diagnoses, including lymphedema, methicillin-resistant staphylococcus aureus infection, chronic embolism and thrombosis, epilepsy, and chronic venous hypertension with ulcer and inflammation of the lower extremities. The resident's cognition was intact, as indicated by a BIMS score of 15 out of 15. The Director of Nursing (DON) and the Administrator both stated that nursing staff are expected to read the Medication Administration Record (MAR) and medication labels before administering medications to ensure compliance with physician orders. The facility's policy on medication administration was requested but not provided before the survey exit.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving a resident who was physically abused by a CNA. The incident occurred when the CNA allegedly slapped the resident in the face during a night shift. The resident reported feeling unsafe and upset, although no physical injuries were observed. The CNA involved had no prior allegations of abuse or disciplinary actions in her file. The resident involved in the incident had a complex medical history, including conditions such as cellulitis, cerebral infarction, type 2 diabetes, atrial fibrillation, hyperlipidemia, hypertension, paranoid schizophrenia, and chronic ischemic heart disease. The resident also had cognitive deficits, as indicated by a BIMS score suggesting moderate impairment. Despite these challenges, the resident was able to communicate her needs and had previously reported issues to the facility's administration. Interviews with staff revealed that the incident was reported to the facility's administration, and an investigation was initiated. The CNA involved in the incident claimed that the contact was accidental and denied any intention to harm the resident. However, the facility's administration decided to terminate the CNA based on the investigation's findings. The facility had policies in place to prevent abuse, neglect, and exploitation, but the incident highlighted a failure to protect the resident from abuse.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to uphold the resident's right to dignity and privacy, as evidenced by an incident involving a certified nursing assistant (CNA) who entered a resident's room without knocking. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported that staff frequently entered his room without knocking or introducing themselves. This behavior was observed during an interview with the resident when CNA A entered the room unannounced, claiming to check if the lunch tray had been picked up. CNA A, who had been working at the facility since February 2024, acknowledged the mistake and apologized, stating that he was aware of the requirement to knock before entering a resident's room. Despite having received training on resident rights and privacy during onboarding and a recent in-service, CNA A failed to adhere to these protocols. The CNA's supervisor, RN A, confirmed that CNA A had been trained to knock and introduce himself before entering a resident's room and mentioned that CNAs were regularly reminded of this practice. The Director of Nursing (DON) and the facility's administrator reiterated the importance of respecting residents' privacy by knocking and introducing oneself before entering their rooms. Other CNAs at the facility confirmed that they had received similar training and in-services on resident rights, which included the requirement to knock before entering a resident's room. The facility's policy, dated 2022, emphasized the importance of maintaining resident dignity and privacy, including the practice of knocking before entering a resident's room.
Neglect in Incontinence Care for Two Residents
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to carry out activities of daily living, specifically incontinence care. Resident #3, a male with severe cognitive impairment and multiple health issues including dementia and osteoarthritis, required extensive assistance. On the specified date, he was left soiled and unattended, which was discovered by a CNA coming on shift. The resident's care plan indicated the need for frequent checks and incontinence care to prevent skin breakdown, but these were not adhered to. Resident #4, a female with severe cognitive impairment and conditions such as hypertension and type 2 diabetes, was also left soiled. Her care plan similarly required regular incontinence care and monitoring to prevent pressure ulcers. Observations noted that she was found heavily soiled in urine and feces, indicating neglect in her care. Both residents were dependent on staff for assistance with daily living activities, and the failure to provide timely care compromised their dignity and increased the risk of infections. Interviews with staff revealed that CNA F, who was responsible for the residents during the shift, admitted to falling behind and not changing the residents before leaving. The CNA did not inform the oncoming shift or charge nurse about the residents' conditions. The facility's policies on resident dignity and neglect were not followed, as evidenced by the residents being left in a soiled state. The incident was reported to the Administrator, and it was noted that this was not the first time CNA F had failed to perform required care duties.
Resident's Use of Space Heater Highlights Safety Lapse
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards, specifically by allowing a resident to have a working and running electric space heater in his room. This deficiency was identified during observations and interviews with staff and the resident. The resident, who was cognitively intact, had a history of heat intolerance and repeatedly expressed feeling cold, leading him to purchase and use a space heater despite knowing it was against facility policy due to fire safety concerns. The resident's room was observed to be cluttered with various items, including cardboard boxes and plastic lock boxes, which contributed to the potential hazard. Staff interviews revealed that the resident had a pattern of acquiring space heaters, which were removed by staff only for the resident to replace them. The Maintenance Director, who was responsible for adjusting room temperatures and removing space heaters, was not aware of the heater's presence during his rounds, indicating a lapse in monitoring and enforcement of safety policies. Interviews with various staff members, including CNAs, LVNs, and the Maintenance Director, highlighted a lack of consistent communication and action regarding the resident's use of space heaters. Although the facility had a policy in place for maintaining electrical safety, the repeated presence of space heaters in the resident's room demonstrated a failure to effectively implement and enforce this policy, thereby placing the resident and potentially others at risk of harm or injury.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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