The Meadows Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 8383 Meadow Rd, Dallas, Texas 75231
- CMS Provider Number
- 455463
- Inspections on file
- 42
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Meadows Health And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found portable space heaters plugged in on nightstands in two secure-unit rooms, including one heater that was turned on and unattended while the residents were not in the room, even though the central heat was functioning and the rooms were warm. A CNA reported not knowing how long the heaters had been present. The DON, Maintenance Director, and ADM all confirmed there was no facility policy on portable or space heaters, acknowledged these devices as safety hazards that could cause injury, and stated that space heaters had been placed on the unit during a recent heating issue despite an existing heat-loss policy that relied on clothing, blankets, hot beverages, and environmental measures rather than portable heaters.
A resident with dementia, severe cognitive impairment, and multiple psychotropic medications exhibited escalating behavioral episodes, including yelling, kicking, and knocking over furniture, for which PRN Xanax and Haldol were ordered and administered. Following one such episode, staff documentation noted a facial scratch, and a CNA later obtained photos from a confidential source showing scratches to the face and reddened areas on the forearm and hand. One CNA reported that another staff member feared reporting the incident and believed staff had been aggressive with the resident, while another CNA described seeing blood on the resident’s face, swelling around an eye, and bruising to the wrist and hand after the incident. The ADON viewed photos on a CNA’s phone but concluded the markings were related to the behavioral episode and redirection, instructed that the photos be shown to the involved LVN for documentation, and did not initiate an internal abuse or injury‑of‑unknown‑source investigation. The DON and corporate RN later stated they did not see the photos, did not identify injuries on assessment, and determined the situation did not meet criteria for mandatory reporting, resulting in the facility’s failure to immediately report the alleged abuse and suspicious injuries to the administrator and state authorities as required.
A resident with severe cognitive impairment, vascular dementia, schizophrenia, schizoaffective disorder, insomnia, and multiple psychotropic medications did not have a comprehensive, person-centered care plan that addressed behaviors or psychotropic use. The current care plan omitted identified behaviors, high-risk psychotropic medications, and recent behavioral incidents that led to PRN administration of IM haloperidol and Xanax. Due to an ownership change and transition to a new electronic system, existing care plans did not transfer, and the MDS nurse, who was responsible for psychotropic-related care planning, had not yet rebuilt this resident’s individualized behavior-based care plan in accordance with facility policy requiring measurable objectives, timeframes, and ongoing revision.
A resident with dementia and severe cognitive impairment, receiving multiple psychotropic medications, was given PRN IM Haldol for resistance to care and reported combative behavior without clear documentation of behaviors or danger to self or others. The care plan did not reflect psychotropic use or recent behavioral incidents, and behavior monitoring logs showed no behaviors at the time PRN psychotropics were administered. Staff accounts of the resident’s behavior conflicted, with some describing effective de-escalation through calm redirection and others describing aggression and destructiveness. The facility’s antipsychotic policy required documented behavioral symptoms posing danger, prior behavioral interventions, and specific documented conditions for PRN psychotropic use, but these criteria and related documentation were not met, resulting in the use of an unnecessary antipsychotic medication.
Four residents with severe cognitive and mobility impairments were found to have their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews indicated that call lights were not always returned to accessible positions after care, and nursing staff acknowledged responsibility for ensuring accessibility. The facility's policy required accessible call systems, but this was not consistently followed.
A resident with COPD who required BPAP and continuous oxygen therapy was observed with a nasal canula dragging on the floor and a BPAP mask left unbagged on a nightstand. Nursing staff and administration confirmed that both items should have been bagged when not in use to prevent contamination, but this was not done, contrary to facility policy.
Two residents receiving oxygen therapy for COPD were not accurately documented in their MDS assessments, despite care plans, physician orders, and treatment records confirming ongoing oxygen use. Staff interviews confirmed the omission, and observations showed one resident actively receiving oxygen during the survey.
Two residents with COPD did not receive respiratory care in accordance with professional standards and physician orders. One resident's nasal cannula was visibly soiled and not replaced, while another's oxygen concentrator humidification bottle was not dated, making it unclear if required maintenance was performed. Staff interviews revealed inconsistent practices and lack of documentation regarding respiratory equipment changes.
Two residents with limited range of motion did not receive appropriate contracture management after therapy discharge. One resident, with severe cognitive impairment and hemiplegia, was observed without a splint despite having an order for contracture management. Another resident, with moderate cognitive impairment and a history of stroke, was also seen without a splint, indicating a lack of staff awareness and implementation of necessary interventions. This deficiency highlights a failure in communication and execution of therapy recommendations, risking further decline in residents' conditions.
The facility failed to ensure proper pharmaceutical services, including the counting and documentation of controlled drugs and the use of an expired insulin pen for a resident. Controlled drugs were not signed off at shift changes, risking drug diversion, and an expired insulin pen was used for a resident with diabetes, potentially compromising medication effectiveness.
Two residents in the facility did not receive necessary dental services, leading to potential risks such as mouth pain and difficulty eating. One resident reported tooth pain and discomfort, while another had difficulty eating due to dental issues. Despite these needs, the facility lacked a clear process for managing dental care, and staff were unaware of the residents' needs. The Social Worker, responsible for tracking ancillary services, was newly hired and developing a system to address these issues.
The facility's kitchen failed to meet food safety standards, with uncovered food items in the freezer and hot holding temperatures below 135°F during lunch service. A staff member initially served food at improper temperatures, later realizing the mistake after consulting with the Dietary Manager. The facility's policies and FDA guidelines require hot foods to be served at 135°F or greater to prevent foodborne illnesses.
The facility failed to maintain sanitary conditions in clean linen closets, where non-linen items were found, posing a risk of cross-contamination. Additionally, a CNA did not perform proper hand hygiene during incontinence care for a resident with severe cognitive impairment, increasing the risk of infection. The facility's policies require proper linen handling and hand hygiene, but these were not adhered to, as confirmed by staff interviews and observations.
The facility failed to maintain proper hygiene and grooming for two residents, resulting in long and unclean fingernails. One resident, cognitively intact, expressed discomfort due to nail length but did not report it, while another, cognitively impaired, had discolored and dirty nails. Staff were responsible for nail care, but oversight led to this deficiency, posing infection control risks.
A facility's secured unit had an unlocked shower room and cabinet containing personal care products and razors, posing risks to residents. Staff interviews revealed a lack of clear policy and training on securing these areas, with the DON and Administrator acknowledging the oversight.
A resident with severe cognitive impairment was recorded by an unauthorized visitor who signed in as a volunteer. The visitor posted the recording on social media, leading to a breach of privacy. The resident's family was upset upon discovering the video. The facility's DON acknowledged the violation of resident rights, as the facility's policy did not cover visitor conduct regarding recordings.
A resident in a memory care unit was verbally abused by an Activities Assistant, who referred to the resident as a 'pig' during an interaction. The incident was recorded and posted online by an unauthorized visitor, causing embarrassment and a loss of dignity for the resident. The facility lacked a specific policy on social media or recording by non-employees, contributing to the deficiency.
An LTC facility failed to report an incident where an Activities Assistant spoke rudely to a resident, making derogatory comments about her eating habits. The incident, captured in videos, was not reported to the state as required, despite the resident's family informing the facility. The resident, with a severely impaired BIMS score and multiple diagnoses, was at risk due to this reporting failure.
Use of Portable Space Heaters in Resident Rooms Without Policy or Controls
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental safety on the secure unit when portable space heaters were found in resident rooms despite the central heat functioning. During observation with a CNA, one resident room contained a portable space heater plugged into the wall and turned on, sitting on a nightstand with a digital temperature display reading 85 degrees Fahrenheit, while neither the resident nor the roommate were present in the room. Another resident room contained a portable space heater plugged into the wall on the nightstand; this heater was not turned on, and the resident was in bed without a roommate. The CNA reported not knowing how long the heaters had been in the rooms and confirmed that the heat was working and both rooms were warm. Interviews with the DON, Maintenance Director, and Administrator revealed that the facility did not have a policy on portable or space heaters in resident rooms, and each acknowledged that such heaters were considered a safety hazard and could result in injury. The Maintenance Director stated that space heaters had been placed on the secure unit on a specific date when reports were received that heaters were not functioning properly, and that an HVAC company had been contacted and repairs to a valve were completed within a couple of hours that same day, after which the heat was working. Despite this, space heaters remained in at least two resident rooms on the secure unit. Review of the facility’s Loss of Central Services Policy for heat loss showed procedures focusing on clothing, blankets, hot beverages, activities, and environmental measures such as closing windows and drawing curtains, with no mention of using portable or space heaters.
Failure to Report and Investigate Alleged Abuse and Suspicious Injuries
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported and investigated in accordance with state and federal requirements. The resident was an elderly male with metabolic encephalopathy, vascular dementia, diabetes, insomnia, and severe cognitive impairment (BIMS score of 6), who required moderate assistance with ADLs, used a walker, and was frequently incontinent. He was receiving multiple psychotropic and high‑risk medications, including Seroquel, Depakote, Trazodone, Remeron, and later PRN Xanax and Haldol for agitation and behavioral issues. Nursing notes documented escalating outbursts and aggressive behavior on multiple dates, including yelling, kicking, hitting, scratching staff, and knocking down tables and chairs, with new PRN psychotropic orders obtained. A late entry note on 12/30/25 documented a scratch to the right side of the resident’s face. Staff interviews revealed conflicting accounts of the behavioral incident(s) and the resident’s injuries. One CNA reported that on the morning of 12/24/25 the resident resisted ADL care, was taken to the dining room, began knocking on the table and making noise, and was then removed to his room; she stated she did not observe bruises or injuries afterward. Another CNA (CNA D) reported that around 12/30/25 a staff member contacted her, expressing fear about reporting what occurred and believing staff on the secured unit had been aggressive with the resident and harmed him. CNA D stated she had photos showing scratches and reddened areas on the resident’s face, forearm, and hand, and that she showed these photos to the ADON. She reported that the ADON told her she already knew about the incident, stated the resident had struck the nurse’s nose, and instructed her to show the photos to the same nurse (LVN A) so the nurse could document any injuries. CNA D believed no formal abuse or injury‑of‑unknown‑source investigation was initiated, that the incident was not reported to the state, and that alleged involved staff were not removed from the resident’s care. Additional interviews further demonstrated that an allegation of possible abuse and suspicious injuries was not treated as a reportable incident. LVN A acknowledged a behavioral episode in the dining room, stated the resident hit her nose, and later described the resident as wild and flailing, asserting that a facial scratch was self‑inflicted. The ADON stated she was present shortly after the behavioral escalation, saw the resident in his room, and later viewed photos on a CNA’s phone showing redness/scratches, but she did not believe the photos indicated abuse and did not initiate an internal abuse investigation, concluding any markings were related to the behavioral episode and redirection. The DON and corporate nurse reported they became aware of concerns only when state surveyors arrived, did not personally see the photos, and did not identify injuries on subsequent assessments; they stated the situation did not meet criteria for mandatory reporting to HHSC and no staff were suspended. Another CNA (CNA E) described hearing loud commotion, observing staff using loud, commanding voices, and later seeing blood running down the resident’s face, swelling around the eye, and bruising to the wrist and hand; she expressed fear of retaliation and concern that internal reporting mechanisms were not safe. Despite these staff concerns, photographic evidence of injuries, and the state’s definition requiring reporting of suspected abuse and suspicious injuries of unknown source, the facility did not immediately report the allegation or initiate a formal abuse or injury‑of‑unknown‑source investigation as required.
Failure to Develop and Implement Comprehensive Psychotropic and Behavior Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple psychiatric and medical diagnoses who was receiving psychotropic medications. Record review showed that the resident, an older male with metabolic encephalopathy, vascular dementia, diabetes, schizophrenia, schizoaffective disorder, and insomnia, had a quarterly MDS indicating severe cognitive impairment, use of high-risk medications (including antipsychotics and antidepressants), and functional limitations requiring assistance with ADLs. Despite these identified needs and conditions, the current care plan initiated in late December did not identify any behaviors, did not address the use of psychotropic medications, and did not include individualized behavior-based interventions. The record further showed that the resident had active orders for multiple psychotropic and related medications, including IM haloperidol as a one-time dose for restlessness and agitation, PRN Xanax for restlessness and agitation, mirtazapine for insomnia, Seroquel for vascular dementia, trazodone for depression, and Depakote for vascular dementia. The MAR documented administration of PRN Xanax and PRN IM Haldol during the review period. However, the resident’s current care plan did not address these medications, their indications, or associated behavioral symptoms, and did not incorporate the acute behavioral incidents that led to the PRN antipsychotic and anxiolytic use. Interview with the MDS nurse revealed that a change of ownership and transition to a new online system resulted in existing care plans not transferring, requiring all residents’ care plans to be rebuilt. The MDS nurse stated she was responsible for care planning residents on psychotropic medications and acknowledged that, during this transition, she had not yet updated this resident’s care plan, even though the resident was on her list. She was uncertain whether other licensed nurses could update care plans for acute or new issues. The facility’s own policy on comprehensive person-centered care plans required measurable objectives, timeframes, and ongoing revision of care plans as residents’ conditions changed, including addressing underlying sources of problem areas, but these requirements were not met for this resident’s behavioral and psychotropic medication needs.
Unnecessary PRN IM Antipsychotic Use Without Adequate Indications or Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary psychotropic medication, specifically PRN intramuscular (IM) Haldol, and to ensure adequate indications and documentation for its use. The resident was an elderly male with metabolic encephalopathy, vascular dementia, diabetes, insomnia, and previously documented but later unsubstantiated diagnoses of schizophrenia and schizoaffective disorder. A quarterly MDS showed severe cognitive impairment with no documented delirium, negative mood, or verbal/physical behaviors toward others. The resident required moderate assistance with ADLs, used a walker, and was frequently incontinent. His care plan initiated in late December did not identify behaviors or psychotropic medication use and did not address acute behavioral incidents that occurred later in the month or the new PRN psychotropic orders. The resident’s psychotropic regimen included Seroquel for agitation, Depakote sprinkles for mood disorder, Trazodone for agitation and dementia, and Remeron for insomnia. A psychiatric NP evaluation shortly before the incidents documented the resident as calm, with dementia and insomnia, and noted no supporting evidence for schizophrenia or schizoaffective disorder, recommending removal of those diagnoses. Subsequent physician orders included a one-time IM Haldol dose for restlessness and agitation, and PRN Xanax for restlessness and agitation. The MAR showed administration of PRN Xanax and PRN IM Haldol, but the behavior monitoring section did not document any behaviors at the time of PRN administration. Nursing notes described the resident as having outbursts, yelling “mama, mama,” and attempting to kick staff, with reports of aggressive behavior and knocking down tables and chairs, but these behaviors were not reflected in the behavior monitoring logs or care plan. On one occasion, staff reported the resident resisted incontinent care, was taken to the dining room, and began yelling and interacting with furniture, after which he was returned to his room and later given PRN Xanax. On another morning, the nurse described the resident as destructive and combative in bed, kicking at staff, and decided to administer IM Haldol based on an existing order, stating that oral Xanax had been ineffective because the resident spit it out. Other staff interviews provided differing accounts, with one CNA stating the resident was not normally aggressive, that she did not see him flip tables or chairs, and that he could be calmed with soft redirection, while describing other staff using loud, commanding voices. The facility’s own antipsychotic policy required that antipsychotics for dementia be used only after other causes of behavior were addressed, that behaviors present a danger to the resident or others, that behavioral interventions be attempted, and that PRN psychotropics only be used for specific documented conditions. A clinical leader acknowledged errors including lack of psychotropic medications on the care plan, lack of documented behaviors, and behavior monitoring logs showing zeros despite PRN psychotropic use, and stated that IM antipsychotics should not be used to compel residents to comply with care. The administrator stated IM antipsychotics should only be used when a resident posed a threat to self or others and that resisting care alone would not justify IM antipsychotic use, while affirming residents’ right to refuse care. An observation of the resident after these events found him in a wheelchair at lunch with a full plate of food, eyes closed, slightly slumped, and only slowly beginning to eat after being roused, remaining non-responsive to questions and keeping his eyes closed. No visible injuries were noted. The facility’s antipsychotic policy also specified that antipsychotics should not be used when the only symptoms were restlessness or uncooperativeness and that residents should not receive PRN psychotropics unless necessary to treat a specific documented condition. Despite this, the resident received PRN IM Haldol in the context of resistance to care and combative behavior without clear documentation of danger to self or others, without adequate behavior documentation on the MAR or behavior logs, and without corresponding updates to the care plan, leading surveyors to determine that the resident’s drug regimen was not maintained free from unnecessary drugs.
Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that the resident call light system was accessible to residents in their rooms, as required by facility policy. During observations, four residents with significant mobility limitations and severe cognitive impairments were found to have their call lights out of reach. In each case, the call light was either on the floor, under the bed, or otherwise not accessible to the resident, despite care plans specifying that call lights should be within reach due to their high risk for falls and need for assistance with activities of daily living (ADLs). Staff interviews revealed that the call lights were not returned to accessible positions after care activities such as bathing. In one instance, a restorative aide admitted to forgetting to place the call light within reach after bathing a resident. Other staff members, including CNAs and an LVN, were either unaware of why the call lights were not accessible or acknowledged that it was the responsibility of nursing staff to ensure call lights were within reach. The Director of Nursing confirmed that all staff should be checking to ensure call lights are accessible to residents. Record reviews for the affected residents showed that each had care plans and assessments indicating severe cognitive and physical impairments, requiring substantial or total assistance for ADLs. The facility's own policy required that residents be provided with a means to call staff for assistance from their beds, bathrooms, and bathing areas, but this was not consistently implemented, as evidenced by the observations and staff interviews.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with COPD who required both BPAP and continuous oxygen therapy. On the morning of the survey, the resident was observed sitting in a wheelchair with his nasal canula attached to an oxygen tank, but the canula was dragging on the floor. Additionally, the resident's BPAP mask was found unbagged on top of his nightstand, despite not having been used since early that morning. Both items were not stored in a manner consistent with infection control practices as outlined in the facility's own policy and professional standards. Interviews with nursing staff and administration confirmed that the nasal canula and BPAP mask should have been bagged when not in use to prevent contamination and infection. The RN present was unaware of why the items were not properly stored, and both the DON and ADON acknowledged that it was the nurse's responsibility to ensure proper storage. The facility's policy on oxygen administration also emphasized the need for safe handling and storage of respiratory equipment, which was not followed in this instance.
Failure to Accurately Document Oxygen Therapy in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents who were receiving oxygen therapy. For both residents, the MDS assessments did not document their ongoing oxygen use, despite evidence from care plans, physician orders, and treatment administration records indicating that oxygen therapy was being provided. The omission was identified through observations, interviews, and record reviews conducted by surveyors. One resident, a female with a diagnosis of chronic obstructive pulmonary disease (COPD), had a care plan and physician orders specifying oxygen therapy via nasal cannula at 2 liters per minute as needed. Her care plan included detailed interventions for monitoring respiratory status and safety precautions related to her smoking history. However, her comprehensive MDS assessment did not indicate that she was receiving oxygen therapy during the look-back period, even though her care plan and other records confirmed its use. Another resident, a male also diagnosed with COPD, had physician orders for continuous oxygen via nasal cannula, with instructions to titrate the flow rate and monitor oxygen saturation. His care plan and treatment administration records documented regular maintenance and monitoring of his oxygen equipment. Despite this, his MDS assessment left the section for special treatments, including oxygen therapy, blank. Interviews with facility staff, including the DON and MDS coordinator, confirmed that the MDS assessments were completed without reflecting the residents' actual oxygen use.
Failure to Provide Safe and Consistent Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such care, as evidenced by observations, interviews, and record reviews. One resident with a history of chronic obstructive pulmonary disease (COPD) and a smoking habit was found with a nasal cannula (NC) that had visible discoloration in various shades of brown, which had not been replaced despite being dirty. The resident reported that the NC tubing was never changed and the oxygen concentrator was not cleaned. Physician orders and the care plan specified that oxygen tubing and humidifier bottles should be changed weekly and as needed, but these instructions were not followed. Another resident, also diagnosed with COPD, was observed with an oxygen concentrator humidification bottle that was not dated. Although the resident stated that the nurse checked the tubing and bottle during rounds, he could not recall when the water bottle was last changed. Physician orders required the humidification bottle to be checked for adequate distilled water every shift and the tubing to be changed weekly, but the lack of dating on the bottle made it unclear whether these procedures were being followed as ordered. Interviews with nursing staff and facility leadership revealed inconsistencies in the implementation of respiratory care protocols. Staff acknowledged that tubing was supposed to be changed weekly and as needed, but there was no system in place to date the NC or humidification bottles, and responsibilities for cleaning equipment were not clearly defined. The facility's policy required weekly documentation of tubing changes, but observations and staff statements indicated that these procedures were not consistently carried out, resulting in deficiencies in respiratory care for the residents involved.
Failure in Contracture Management for Residents
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to prevent further decline in their condition. Specifically, two residents, identified as Resident #3 and Resident #12, did not receive adequate contracture management after being discharged from therapy services. Resident #3, a severely cognitively impaired female with a history of cerebral infarction and hemiplegia, was observed without a splint on her contracted hand, despite having an order for contracture management. Interviews with staff revealed a lack of awareness and implementation of the necessary interventions to manage her condition. Resident #12, a male with moderate cognitive impairment and a history of cerebrovascular accident, was also observed without a splint on his contracted left hand. Despite having a care plan and physician orders for contracture management, staff interviews indicated a lack of knowledge about the resident's therapy history and the presence of a splint. The resident was seen grimacing and unable to open his left hand, suggesting discomfort and potential worsening of his condition. The deficiency was further highlighted by the facility's failure to communicate and implement therapy recommendations effectively. Interviews with the Director of Rehabilitation and other staff members revealed that the responsibility for continuing splint orders post-therapy discharge was not clearly understood or executed. This lack of coordination and follow-through placed the residents at risk for further decline in their range of motion and increased dependency on assistance for activities of daily living.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by two main deficiencies observed during the survey. Firstly, the facility did not ensure that controlled drugs were counted and documented at every shift change for Med Aid cart 2 west front. Specifically, there were missing signatures for narcotic counts on two separate dates, indicating that the required procedure of counting and signing off on narcotics was not followed. LVN P admitted to counting the narcotics but forgetting to sign the narcotic sheet, which could potentially lead to drug diversion. The Director of Nursing (DON) confirmed the importance of signing the narcotic count sheet to prevent drug diversion and stated that random checks were supposed to be conducted by the DON and Assistant DON. Secondly, the Nurses cart 2 Central contained an insulin pen for a resident with an expired opened date. The resident, a female with severe cognitive impairment and a history of type 2 diabetes mellitus, was administered insulin from this expired pen. LVN K acknowledged using the expired insulin pen and admitted to forgetting to check the open date, which is crucial as insulin loses effectiveness after 28 days. The DON reiterated the necessity of dating insulin pens upon opening to ensure they are used within their effective period. The facility's policy on medication expiration dates was not adhered to, as evidenced by the expired insulin pen being used for the resident.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that two residents, Resident #8 and Resident #23, received necessary dental services, including routine dental care. Resident #8, a moderately cognitively impaired female, reported experiencing pain and discomfort in two teeth and had requested dental services multiple times over the past year without any action taken by the facility. Despite her complaints, the nursing staff, including RN D and the Social Worker, were unaware of her need for dental care, and no referral had been made for her to see a dentist. Resident #23, also moderately cognitively impaired, expressed difficulty eating due to a lack of teeth and food getting stuck in her teeth. However, she had not communicated these issues to the nursing staff, including CNA H, RN D, and LVN I, who were unaware of her dental needs. The Social Worker confirmed that Resident #23 had not been referred to a dentist in the past year, and her care plan did not address her dental needs. The facility lacked a clear policy or process for managing ancillary services like dental care. The Social Worker, who was responsible for tracking these services, had only recently been hired and was in the process of developing a system to monitor residents' needs. The Director of Nursing and the Administrator were unsure of the frequency with which residents should receive dental care, and the facility did not have a policy in place for routine dental services. This lack of coordination and communication among staff contributed to the failure to provide necessary dental care to the residents.
Deficiency in Food Safety Standards in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, food items such as cut zucchini, cut carrots, cinnamon rolls, and cooked sausages were found uncovered in the walk-in freezer, which could lead to food contamination. Additionally, during a lunch service, the hot holding temperatures for menu items like turnip greens, mashed potatoes, and pureed vegetables were below the required 135°F. The staff member responsible for measuring these temperatures, [NAME] A, initially believed it was acceptable to serve food below 135°F as long as it was in a steaming water bath, but later acknowledged the mistake after consulting with the Dietary Manager. The Dietary Manager confirmed that all foods in the freezer should be covered and that hot foods should be held at temperatures above 135°F to prevent foodborne illnesses. The manager also stated that the cook should have taken corrective actions to ensure the food was at the proper temperature before serving. The facility's policy and the FDA Food Code require that hot foods be served at 135°F or greater, and the failure to comply with these standards could lead to foodborne illness among residents. The Administrator emphasized the importance of following state and federal food safety regulations to prevent such risks.
Infection Control Deficiencies in Linen Storage and Resident Care
Penalty
Summary
The facility failed to maintain a sanitary environment in its clean linen closets, which were observed to contain items that posed a risk of cross-contamination. During an inspection, a cart with a broken bottom shelf was found in the clean linen closet of the secured unit, containing bagged clothes without identification, personal hygiene items, and clean linens. Additionally, a black vest was hanging on the clean linen cart. Staff interviews revealed uncertainty about the cart's presence and acknowledged that non-linen items in the closet could lead to infections. A similar issue was observed in another unit, where a cardboard box with personal items was found near the clean linen cart. The facility also failed to ensure proper hand hygiene during incontinence care for a resident with severe cognitive impairment and total urinary incontinence. During care, a CNA did not perform hand hygiene between glove changes while cleaning the resident, which could lead to cross-contamination. The CNA acknowledged the mistake and stated she was trained to sanitize hands between glove changes. The DON confirmed that staff are expected to sanitize hands when transitioning from dirty to clean tasks to prevent infection spread. The facility's policies on infection control and hand washing were reviewed, indicating that linens should be properly stored and handled to minimize contamination, and that staff must wash hands before and after resident care and after removing gloves. The DON and ADON were identified as responsible for ensuring safe practices to control infection spread, but the observed deficiencies indicate lapses in adherence to these policies.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Two residents, identified as Resident #30 and Resident #48, were observed with long and unclean fingernails. Resident #48, a cognitively intact male with a history of cerebral infarction and muscle weakness, required moderate assistance with personal hygiene. Despite his care plan indicating the need for assistance with ADLs and keeping fingernails cut, his nails were found to be 0.4 cm long, and he expressed discomfort due to their length. He did not report this to staff as he perceived them to be busy. Resident #30, a cognitively moderately impaired male with cerebral infarction and hemiplegia, was dependent on staff for personal hygiene. His care plan required regular checking and trimming of nails. However, his nails were observed to be 0.4 cm long, discolored, and dirty. Staff interviews revealed that both CNAs and nurses were responsible for nail care, but the oversight led to the deficiency. The Director of Nursing acknowledged that nail care should be completed as needed and observed daily, highlighting the risk of infection control issues due to long and dirty nails.
Unsecured Shower Room and Cabinet in Secured Unit
Penalty
Summary
The facility failed to maintain a secure environment in the secured unit's shower room, which was observed to be unlocked on multiple occasions. Inside the unlocked shower room, a cabinet was also found unlocked, containing various personal care products and an opened razor box. These unsecured items posed potential risks to residents, particularly those who might wander into the room and accidentally ingest or misuse the products, leading to possible injuries or falls. Interviews with staff, including a CNA, an LVN, the DON, and the Administrator, revealed a lack of clarity and enforcement regarding the locking of the shower room and cabinet. The CNA and LVN acknowledged the importance of keeping the room locked to prevent accidents, but there was uncertainty about who held the keys to the cabinet. The DON admitted there was no specific policy on accident prevention in the secured unit and could not recall when staff were last trained on safety practices. The Administrator also recognized the risk posed by unlocked doors but confirmed the absence of a formal policy addressing these hazards.
Breach of Resident Privacy Due to Unauthorized Recording
Penalty
Summary
The facility failed to ensure the personal privacy of a resident, leading to a breach of confidentiality. A visitor, who was not an approved volunteer, was allowed to sign in as a volunteer and subsequently recorded a resident during their visit. The visitor then posted the recording on social media, which was discovered by the resident's family. The resident, a female with a severe cognitive impairment as indicated by a BIMS score of 05, was recorded in the dining hall of the memory care unit during interactions with the Activities Assistant and the visitor. The resident's family expressed their anger and concern over the incident, noting that the resident did not remember the event but recalled eating cupcakes. The Director of Nursing (DON) acknowledged the breach of privacy and stated that the facility's policy only covered staff and electronic monitoring, not visitors. The facility's policy on resident rights, dated 2018, affirms the right to privacy, including during visits and personal needs. The DON and the Administrator both agreed that residents should not be recorded without their permission, as it violates their rights. The facility was still investigating how the visitor gained access and why the recording was made.
Resident Verbal Abuse and Unauthorized Recording
Penalty
Summary
The facility failed to protect a resident from verbal abuse and unauthorized recording, which led to a deficiency in ensuring residents' rights to be free from abuse and neglect. A resident, who was severely impaired with a BIMS score of 05, was referred to in a derogatory manner by an Activities Assistant. The assistant called the resident a 'pig' during an interaction that was recorded and posted online by a visitor who was not an approved volunteer. The incident occurred in the dining hall of the memory care unit, where the resident was interacting with a visitor. The Activities Assistant made inappropriate comments about the resident's eating habits and instructed the resident to clean up after herself in a manner that was deemed disrespectful. The visitor, who was allowed to sign in as a volunteer without proper approval, recorded the interaction and shared it on social media, causing embarrassment and a loss of dignity for the resident. The resident's family was upset upon discovering the video online and expressed their concerns to the facility's Director of Nursing (DON) and Administrator. The facility's policy on abuse and resident rights emphasizes the importance of treating residents with dignity and respect, and the incident highlighted a failure to adhere to these standards. The facility did not have a specific policy regarding social media or recording by non-employees, which contributed to the deficiency.
Failure to Report Verbal Mistreatment Incident
Penalty
Summary
The facility failed to report an incident involving verbal mistreatment of a resident by an Activities Assistant within the required timeframe. The incident occurred on Thanksgiving Day when the Activities Assistant spoke rudely to a resident, calling her names and making derogatory comments about her eating habits. This interaction was captured in two videos posted online, which showed the Activities Assistant making inappropriate remarks to the resident in the presence of a visitor. The facility's Director of Nursing (DON) and Administrator were made aware of the incident by the resident's family during the Thanksgiving weekend. The resident involved was an elderly female with a diagnosis of Mood Disorder, Insomnia, Essential Hypertension, and Restlessness and Agitation, and had a severely impaired BIMS score. Despite the facility's policy requiring immediate reporting of such incidents, the Administrator admitted that the incident was not reported to the state, and no reason was provided for this failure. The Activities Assistant was placed on investigatory suspension following the incident, but the lack of timely reporting could place residents at risk of continued abuse or mistreatment.
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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