The Oaks At Longview
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Texas.
- Location
- 111 Ruthlynn Dr, Longview, Texas 75601
- CMS Provider Number
- 675379
- Inspections on file
- 26
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at The Oaks At Longview during CMS and state inspections, most recent first.
A resident with diabetes and severe cognitive impairment did not receive a physician-ordered diabetic diet, despite elevated HGBA1C levels and family requests. Facility staff were unaware or misinformed about the availability of diabetic diets, and the dietary manager and RD were not notified of the need for a special diet. The attending physician was not informed of the family's request until prompted by a surveyor, and the facility's policy for therapeutic diets was not followed.
The facility did not promote or facilitate resident self-determination by failing to support resident choice, as required by regulations.
Residents were not given the opportunity or support to organize and participate in resident or family groups, as required by regulations.
A resident with severe cognitive impairment was exposed to excessive noise in the dining area when loud gospel music and a television were played simultaneously, causing distress. Despite care plan interventions to reduce distractions, staff were unaware of prior complaints and did not ensure a comfortable environment as required by facility policy.
Two residents had MDS assessments that inaccurately documented the use of anticoagulant medications, despite physician orders and care plans indicating they were only prescribed antiplatelet medications such as aspirin and clopidogrel. Staff interviews confirmed the assessments were marked incorrectly, and facility policy requiring accurate use of the RAI for MDS processes was not followed.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A facility failed to perform weekly skin assessments for four residents, as required by their care plans and policy. The Treatment Nurse was off work during the missed assessments, and the responsibility was not effectively delegated to charge nurses. This oversight occurred despite a new EMR system designed to alert staff when assessments were due.
The facility failed to obtain informed consent for psychotropic medications for five residents, as required by policy. Interviews revealed that staff were unclear about the process for obtaining consents, and the responsible ADON was unavailable. This resulted in medications being administered without residents or their responsible parties being informed of the risks and benefits.
The facility failed to implement its abuse prevention policies by not conducting required criminal background checks and EMR reports for certain staff members, potentially placing residents at risk. Interviews revealed a lack of clarity in responsibilities for these checks, despite policies mandating them.
The facility failed to accurately code the MDS assessments for three residents, omitting diagnoses of anxiety, depression, and bipolar disorder. This oversight, attributed to a staff member in training, led to discrepancies between the residents' actual conditions and their documented assessments, potentially affecting their care plans.
The facility failed to conduct annual competency evaluations for five CNAs, as revealed by a review of personnel files. The DON and ADM acknowledged that the lack of evaluations could lead to inadequate care due to CNAs not being informed of new processes. The facility also lacked a policy for staff development and training, as confirmed by the employee handbook.
The facility failed to ensure adequate behavior and side effect monitoring for several residents prescribed psychotropic medications. A resident did not have side effect monitoring for Seroquel, Buspirone, Venlafaxine, and Remeron, while another lacked monitoring for Paroxetine and Lorazepam. Additionally, a resident was prescribed Depakote without proper monitoring, and another was given Seroquel and Hydroxyzine without an appropriate diagnosis or monitoring. Staff acknowledged the importance of these measures but did not implement them effectively.
The facility failed to document and administer influenza and pneumococcal vaccinations to 19 residents, as revealed through interviews and record reviews. The DON and ADM were unaware of these deficiencies, despite acknowledging the importance of vaccinations. The ADON noted that vaccines were offered during admission, but records were not accurately maintained, contrary to the facility's policies.
The facility failed to provide the required 12 hours of annual in-service training for CNAs, affecting five staff members. Interviews revealed confusion over responsibility for training records, with HR, the DON, and the ADM all indicating different roles. The absence of a policy for staff development and training was confirmed, potentially placing residents at risk due to untrained staff.
A resident with dementia and Parkinsonism was instructed by staff to urinate in her brief, compromising her dignity. Despite requiring assistance for toileting, staff failed to respond to her call light, leading to her family taking her home. Interviews revealed that while staff generally tried to assist, inappropriate instructions were given, which the DON and ADM acknowledged as a dignity issue.
A resident with dementia and cognitive impairments developed a bruise on her jaw, which was not reported as an injury of unknown origin within the required timeframe. The facility attributed the bruise to the resident's habit of sleeping with a bed controller and a baby doll, but failed to report it to the state agency as required by their abuse prevention policy.
A resident with Alzheimer's disease was observed using a wheelchair with dried substances and tangled hair on the wheels, indicating a lack of cleanliness. Interviews with staff revealed confusion over responsibilities for cleaning and maintaining wheelchairs, with CNAs and maintenance both cited as responsible. The deficiency highlights an infection control issue due to the unclean wheelchair.
A facility failed to complete a baseline care plan for a newly admitted resident with dementia within 48 hours, as required by policy. The resident's responsible party was not involved in care planning or provided with a care plan copy. Staff interviews revealed confusion about responsibility for care plan initiation and completion, leading to the deficiency.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in addressing their needs. One resident's care plan did not include the use of a necessary bed rail, while another resident lacked a smoking care plan and quarterly assessments for smoking and elopement risk. Staff interviews revealed confusion about responsibilities for updating care plans and completing assessments, resulting in potential risks to residents' safety and well-being.
A facility failed to document catheter orders and care for a resident with an indwelling urinary catheter, leading to potential risks of urinary tract infections. The resident, with chronic kidney disease, was admitted without documented catheter size, bulb fluid amount, or care orders. Staff interviews revealed the omission was due to a new charting system and lack of training. Facility policies emphasized the need for complete documentation to prevent infections.
A resident with COPD and respiratory failure did not receive proper respiratory care as their nasal cannula and nebulizer mask were not stored in bags when not in use. Observations and staff interviews confirmed this oversight, which could lead to contamination and respiratory infections. Facility policy requires such equipment to be free from microorganisms.
A dietary aide in the facility's food and nutrition service department did not obtain a required food handler's certificate, despite being hired months prior and receiving multiple reminders. The lack of certification was attributed to unclear responsibilities among staff and management transitions, potentially impacting food safety for all residents.
A facility failed to maintain safe wheelchair equipment for a resident with Alzheimer's, resulting in a loose brake handle. Staff, including a CNA and maintenance supervisor, acknowledged the risk of falls but had not previously identified the issue. Despite expectations for staff to report equipment problems, the facility did not provide a policy on maintenance responsibilities.
Failure to Provide Physician-Ordered Therapeutic Diabetic Diet
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a therapeutic diabetic diet was prescribed and provided to a resident with type 2 diabetes mellitus, noninfective gastroenteritis and colitis, and gastrointestinal hemorrhage. The resident, who had severely impaired cognition and required assistance with eating, was admitted with a history of diabetes and had care plan interventions indicating the need for a diabetic diet and small, frequent meals. However, the electronic health record and care plan did not reflect an order for a therapeutic diet, and the nutrition assessment did not address the resident's diabetes or the need for small, frequent meals. Despite elevated HGBA1C levels documented in the resident's record, family members' concerns about uncontrolled blood sugars, and requests for a diabetic diet, facility staff—including the ADON and LVNs—communicated to the family that a diabetic diet was not available. The dietary manager and registered dietitian were not made aware of the need for a diabetic diet or small, frequent meals, and no diet order was provided to the kitchen. The registered dietitian had not assessed the resident, as the resident had not triggered for assessment based on the facility's criteria. The attending physician was not informed of the family's request for a diabetic diet and only became aware after state surveyor intervention. The physician stated that he would have ordered a diabetic diet if he had been informed. The facility's own policy required physician orders for therapeutic diets and consultation with the registered dietitian, but these procedures were not followed, resulting in the resident not receiving the prescribed therapeutic diet.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Support Resident/Family Group Participation
Penalty
Summary
The facility failed to honor the right of residents to organize and participate in resident and family groups. This deficiency was identified based on observations and interviews indicating that residents were not provided the opportunity or support to form or participate in such groups within the facility. There were no specific details provided about individual residents, their medical history, or their condition at the time of the deficiency.
Failure to Maintain Comfortable Noise Levels in Dining Area
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment by not ensuring a comfortable noise level in the dining room for a resident with severe cognitive impairment. During a lunch meal, gospel music was played loudly over a speaker while the television was also on, resulting in the resident covering her ears and expressing that it was too loud. The resident, who had a history of dementia, stroke, and traumatic brain injury, was observed to be distressed by the noise and indicated that the music was often played too loudly. Her care plan included interventions to reduce distractions such as turning off the TV or radio. Staff interviews revealed that the music and television were not usually played simultaneously, and staff were generally unaware of any prior complaints about noise levels from the resident. The staff responsible for entertainment and the DON both stated that they would have turned down the music if a complaint was made, but were not aware of any previous issues. The facility's policy emphasized the importance of maintaining comfortable noise levels to create a homelike atmosphere, but this was not followed during the observed incident.
Inaccurate MDS Medication Assessment for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the MDS assessments incorrectly indicated the use of anticoagulant medications, when in fact, physician orders and care plans showed that they were prescribed antiplatelet medications (aspirin and clopidogrel) and not anticoagulants. The care plans for both residents specifically addressed antiplatelet therapy and related interventions, and there were no orders for anticoagulant medications in their records. Interviews with facility staff, including the MDS Coordinator, ADON, DON, and Administrator, confirmed that the MDS assessments were marked incorrectly regarding anticoagulant use. The MDS Coordinator acknowledged the error and was unsure how the incorrect information was entered. The facility's policy required the interdisciplinary team to utilize the Resident Assessment Instrument (RAI) for all MDS processes, but this was not followed accurately in these cases.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not perform weekly skin assessments for four residents, as required by their care plans and facility policy. Resident #1 did not have skin assessments documented on two occasions, while Residents #2, #3, and #4 missed one weekly assessment each. These lapses in care could lead to skin issues being missed or deteriorating without proper monitoring. Resident #1, a female with dementia and other health conditions, was at moderate risk for impaired skin integrity. Her care plan required weekly skin assessments, but assessments were not documented for two weeks in August 2024. Resident #2, also with dementia and other conditions, was at minimum risk for skin issues but missed one weekly assessment. She had a history of redness and yeast rash under her breasts, which required treatment. Resident #3, severely cognitively impaired, and Resident #4, with bipolar disorder and other diagnoses, also missed one weekly skin assessment each, although they did not have documented skin impairments at the time. The Treatment Nurse, responsible for conducting these assessments, was off work during the week when the assessments were missed. The Director of Nursing (DON) stated that charge nurses were responsible for completing assessments in the Treatment Nurse's absence, but this was not effectively communicated or executed. The facility had recently implemented a new electronic medical record (EMR) system, which was supposed to alert staff when assessments were due, but this system did not prevent the oversight. The lack of documentation and missed assessments were attributed to an oversight and inadequate delegation of responsibilities during the Treatment Nurse's absence.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the consent for psychoactive medication therapy. This deficiency was identified for five residents who did not have completed consent forms for their prescribed psychotropic medications. These medications included Duloxetine and Haloperidol for one resident, Depakote for another, Seroquel for a third, Paroxetine for a fourth, and Hydroxyzine and Mirtazapine for the fifth resident. The absence of these consents indicates that the residents or their responsible parties were not informed of the risks and benefits of the medications, nor were they given the opportunity to choose their preferred treatment options. Interviews with facility staff revealed a lack of clarity and responsibility in obtaining these consents. The Director of Nursing (DON) and Licensed Practical Nurse (LPN) both acknowledged that nurses were responsible for obtaining consent for psychotropic medications, which should be done before administering the medication. However, the DON admitted to not knowing the process for monitoring the acquisition of these consents, and the Assistant Director of Nursing (ADON), who was responsible for ensuring consents were obtained, was unavailable due to a family situation. The Administrator (ADM) also stated that consents should be obtained on admission and that verbal consent could be obtained and signed later, but this process was not effectively implemented. The facility's policy on Psychotherapeutic Drug Management, revised in October 2022, clearly states that informed consent must be obtained and documented by the attending physician before administering psychotherapeutic medication, except in emergencies. Despite this policy, the facility failed to adhere to these guidelines, resulting in the administration of psychotropic medications without the necessary informed consent. This oversight could potentially place residents at risk of receiving treatment without being fully aware of the associated risks and benefits.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent mistreatment, neglect, and abuse of residents, as evidenced by the lack of criminal history background checks for three staff members (CNA F, CNA G, and the DOR) and the absence of an EMR report for CNA H in their personnel files. These omissions were identified during a personnel file review conducted on July 16, 2024. The facility's Abuse Prevention and Prohibition Program policy, revised in October 2022, mandates the screening and training of employees to protect residents and ensure a standardized methodology for preventing, identifying, investigating, and reporting abuse. However, the facility did not adhere to these requirements, potentially placing residents at risk for an unsafe environment and abuse. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for conducting background checks and maintaining personnel files. The HR Payroll, who had been at the facility for four months, stated that she was responsible for background checks and EMR reports but was not informed by the previous HR Payroll about the frequency of these checks. The DON and ADM confirmed that HR was responsible for performing these checks upon hire and annually. The facility's Employee Handbook, dated November 2020, emphasizes the importance of conducting reference checks, criminal background checks, and other background checks to maintain a workforce of high integrity. Despite these policies, the facility's failure to conduct the necessary checks could lead to the employment of individuals with criminal histories or misconduct on their licenses.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the diagnoses of three residents, which could potentially place them at risk of not having their individual needs met. Resident #31, a female with diagnoses of anxiety and depression, was not coded for these conditions on her MDS, despite being prescribed an antianxiety medication. Her care plan indicated a potential for drug-related complications due to anxiolytic medications, yet her MDS did not reflect her mental health diagnoses. Similarly, Resident #33, who had diagnoses of bipolar disorder and depression, was not coded for these conditions on her MDS. She was prescribed antipsychotic, antianxiety, and antidepressant medications, and her care plan noted potential drug-related complications due to psychotropic drug use. However, her MDS did not include her bipolar and depression diagnoses, which are crucial for accurate care planning. Resident #54, diagnosed with depression, also had an inaccurate MDS that did not reflect her condition, despite being prescribed antianxiety and antidepressant medications. Her care plan included interventions for depression, yet her MDS failed to indicate this diagnosis. Interviews with the MDS coordinator and other staff revealed that the inaccuracies were due to another staff member in training completing the MDS assessments without proper oversight, leading to discrepancies between the residents' actual conditions and their documented assessments.
Failure to Conduct Annual CNA Competency Evaluations
Penalty
Summary
The facility failed to conduct annual competency evaluations for five Certified Nurse Assistants (CNAs), identified as CNA J, CNA F, CNA H, CNA K, and CNA G. This deficiency was discovered through a review of personnel files, which revealed that none of these CNAs had a competency evaluation on file. The dates of hire for these CNAs ranged from 2002 to 2017, indicating that the evaluations had been overdue for a significant period. The Director of Nursing (DON) acknowledged that the staffing coordinator was responsible for ensuring these evaluations were completed annually, but this had not been done. During interviews, both the DON and the Administrator (ADM) expressed concerns that without proper training and evaluations, CNAs might not be aware of changes or new processes, potentially leading to inadequate care for residents. The ADM confirmed that the facility lacked a policy for staff development and training, which was corroborated by the absence of such a policy in the employee handbook. The handbook did mention that performance reviews should occur 90 days after hire and annually thereafter, but this procedure was not followed, resulting in the deficiency.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of several residents were free from unnecessary psychotropic drugs due to inadequate behavior and side effect monitoring. Specifically, Resident #33 did not have side effect monitoring for her prescribed medications, including Seroquel, Buspirone, Venlafaxine, and Remeron, during July 2024. Despite being prescribed these medications for conditions such as depression, bipolar disorder, and anxiety, there was no documentation of behavior or side effect monitoring in her medical records. Resident #35 also experienced a lack of behavior and side effect monitoring for her prescribed medications, Paroxetine and Lorazepam, during the same period. The facility's records did not include orders for monitoring these medications, which are used to treat mood and anxiety disorders. Additionally, Resident #54 was prescribed Depakote for a mood disorder, but there was no documentation of behavior or side effect monitoring for this medication in her records. Furthermore, Resident #69 was prescribed Seroquel and Hydroxyzine without an appropriate diagnosis, and there was no behavior or side effect monitoring documented for these medications. The facility's staff, including the MDS coordinator, LPN, and DON, acknowledged the importance of monitoring and appropriate diagnoses for psychotropic medications but failed to implement these measures effectively. This lack of monitoring and appropriate diagnoses could prevent residents from receiving the intended therapeutic benefits of their medications.
Failure to Document and Administer Vaccinations
Penalty
Summary
The facility failed to ensure that the medical records of 19 out of 74 residents included documentation indicating that the residents received education on influenza and pneumococcal immunizations. Additionally, the facility did not offer or administer the influenza and pneumococcal vaccinations to several residents, including those who were not admitted outside of the influenza season. This lack of action was identified through interviews and record reviews, revealing that the facility's vaccination records were not accurately maintained. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator (ADM) highlighted a lack of awareness and responsibility regarding the vaccination status of residents. The DON and ADM acknowledged the importance of vaccinations in preventing illness and reducing symptoms, yet they were unaware of the vaccination deficiencies. The ADON mentioned that vaccines were offered during the admission process, but there was a need to reach out to families or primary care providers for prior vaccine information. The facility's policies on influenza and pneumococcal disease prevention, revised in 2020, required documentation of vaccination status, which was not adhered to in these cases.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that nurse aides received the required in-service training of no less than 12 hours per year, which is necessary for maintaining their competencies. This deficiency was identified for five staff members, specifically CNAs F, G, H, J, and K, whose training records were reviewed and found lacking. The personnel file review indicated that these CNAs did not have the required training hours documented, despite their varying lengths of employment at the facility. Interviews with facility staff revealed a lack of clarity and responsibility regarding the management of training records. The HR Payroll, who had been at the facility for four months, was responsible for maintaining training records but did not ensure the completion of necessary training. The DON was unaware of the process for keeping employee files up to date and indicated that the staffing coordinator was responsible for CNA training and evaluations. The ADM confirmed that HR was responsible for personnel files and acknowledged the absence of a policy for staff development and training. This lack of training and evaluation could result in CNAs working without the necessary knowledge, potentially placing residents at risk.
Resident Dignity Compromised by Inappropriate Staff Instructions
Penalty
Summary
The facility failed to uphold the resident's right to dignity and respect, as evidenced by an incident involving a resident who was instructed by staff to urinate in her brief. This incident involved a female resident with diagnoses of unspecified dementia, insomnia, and Parkinsonism, who required maximal assistance for toilet use and moderate assistance for other activities of daily living. The resident's care plan included interventions to prevent skin breakdown due to incontinence, yet during a phone call with her family member, the resident was reportedly told by staff to urinate on herself when her call light was not answered. This led to the family member taking the resident home that night. Interviews with other residents and staff revealed that the resident often required assistance and sometimes refused help, but staff generally attempted to assist her. However, there were instances where staff suggested she urinate in her brief if she could not use the bathroom promptly. The Director of Nursing and the Administrator acknowledged that instructing a resident to urinate in their brief was inappropriate and a dignity issue. The facility's admission agreement stated that personal and nursing care would be provided according to the resident's care plan, which was not adhered to in this case.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, identified as Resident #35, within the required 24-hour timeframe to the state agency. The incident involved a small bruise on the resident's right jaw, which was discovered by a family member during a visit. Despite the facility's policy requiring immediate reporting of such incidents, the bruise was not reported as an injury of unknown origin. The facility's abuse prevention policy mandates that any allegations of abuse, neglect, or injuries of unknown origin be reported immediately, but no later than two hours after forming suspicion. Resident #35, a female with a history of anxiety disorder and dementia, was noted to have cognitive impairments and behavioral symptoms, including rejection of care. The resident's care plan highlighted her risk for bruises due to fragile skin and other factors. On the day of the incident, the resident's bruise was noted by a family member, and the facility staff attributed it to the resident's habit of sleeping with a bed controller and a baby doll, both of which could have caused the bruise. However, the facility did not consider this an injury of unknown origin, and thus, did not report it to the state agency as required. Interviews with the facility's administration revealed a lack of awareness regarding the resident's history of being resistive to care and agitation. The Administrator, who was responsible for investigating and reporting such incidents, acknowledged the importance of reporting injuries of unknown origin to prevent further harm. Despite this, the facility did not report the incident, potentially placing residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report allegations of abuse timely.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for a resident, specifically regarding the cleanliness of the resident's wheelchair. The resident, an elderly female with Alzheimer's disease, muscle weakness, and mobility issues, was observed using a wheelchair that had a moderate amount of dried substance splattered on the wheels and hair tangled where the wheels and frame connected. This was noted during multiple observations over several days, indicating a lack of regular cleaning and maintenance of the wheelchair. Interviews with facility staff, including a CNA, maintenance supervisor, LPN, DON, and ADM, revealed inconsistencies in the understanding of responsibilities for cleaning and maintaining wheelchairs. While CNAs were generally responsible for wiping down wheelchairs, maintenance was expected to handle more thorough cleaning, such as removing and cleaning the wheels. The staff acknowledged that dirty wheelchairs posed an infection control issue, yet there was a lack of clear protocol or communication to ensure the wheelchairs were kept clean, leading to the observed deficiency.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to complete a baseline care plan for a resident within 48 hours of admission, as required by their policy. The resident, an elderly female with dementia and other behavioral disturbances, was admitted for rehabilitation. Despite being usually understood and having moderately impaired cognition, the resident required various levels of assistance for daily activities. The responsible party for the resident reported not being involved in a care plan meeting or receiving a copy of the baseline care plan. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for initiating and completing the baseline care plans. The MDS coordinator, DON, and other nursing staff provided conflicting information about who was responsible for the baseline care plans. The DON believed the LVN on admission was responsible, while the MDS coordinator and other staff assumed different roles were involved. The facility's policy indicated that a licensed nurse should initiate the care plan, which should be completed within 48 hours of admission. However, due to the lack of clarity and communication among staff, the baseline care plan for the resident was not completed, potentially placing the resident at risk of not receiving appropriate care.
Deficiencies in Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the care plan did not include the use of a positioning bed rail, despite the resident's need for assistance due to left-sided hemiplegia following a cerebral infarction. The resident expressed a desire for a bed rail on the right side for safety and assistance during turning, but this was not documented in the care plan. Interviews with staff revealed a lack of clarity on responsibilities for updating care plans and obtaining necessary orders for bed rails. Another resident, who was a smoker with a history of dementia and nicotine dependence, did not have a smoking care plan or quarterly smoking assessments documented. The resident's care plan also failed to include quarterly elopement risk assessments, despite residing in a secured unit due to a history of wandering and exit-seeking behavior. Staff interviews indicated that smoking and elopement risk assessments were not consistently completed, and there was confusion about who was responsible for these assessments. The facility's policies required comprehensive care plans to address each resident's needs, including the use of bed rails and smoking safety. However, the lack of documentation and adherence to these policies resulted in potential risks to the residents' safety and well-being. The facility's failure to ensure proper care planning and assessment could lead to residents not receiving the necessary care and supervision, increasing the risk of injury or decline in their condition.
Failure to Document Catheter Orders and Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, a female with chronic kidney disease, was admitted to the facility without documented orders for the size and amount of fluid in the bulb of her catheter, nor were there orders for catheter care. This lack of documentation was identified during a survey, and it was noted that the orders were only added to the resident's chart after the surveyor brought it to the attention of the facility staff. Interviews with facility staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed that the catheter orders were not present in the system due to a recent change to a new charting system, which the nursing staff had not been fully trained on. The DON acknowledged that the absence of catheter orders could lead to urinary tract infections and sepsis, as the orders were not being monitored. The staff indicated that standard care should be performed with the catheter, and if orders were missing, they would typically contact the physician to obtain them. The facility's policies on catheter care and physician orders were reviewed, highlighting the importance of complete and accurate documentation to prevent infections and ensure clarity of the physician's plan of care. However, the failure to have these orders in place for the resident's catheter care was a significant oversight, potentially placing the resident at risk for complications associated with improper catheter management.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident who required oxygen therapy. Specifically, the nasal cannula and nebulizer mask used by the resident were not stored in bags when not in use, as observed on two separate occasions. This oversight was confirmed by interviews with facility staff, including an LPN and the Director of Nursing (DON), who acknowledged that the equipment should be stored in bags to maintain sanitation and prevent contamination. The resident involved had a medical history of chronic obstructive pulmonary disease and respiratory failure, requiring continuous oxygen therapy and nebulizer treatments. The facility's policy on cleaning and disinfection indicated that respiratory equipment should be free from microorganisms, highlighting the importance of proper storage. The failure to store the nasal cannula and nebulizer mask correctly could lead to contamination and potential respiratory infections for the resident.
Deficiency in Food Handler Certification for Dietary Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and accreditations in the food and nutrition service department, specifically concerning a dietary aide (DA A) who did not possess a food handler's certificate. DA A was hired on November 3, 2023, and was expected to obtain the certificate within two weeks of hire, but failed to do so despite multiple reminders from the Dietary Manager (DM). The DM acknowledged the responsibility, along with Human Resources (HR), to ensure DA A obtained the certificate. However, the certificate was not acquired, and the DM communicated this issue to HR, who also failed to resolve it. Interviews with various staff, including the Dietician, HR, and the Administrator (ADM), revealed a lack of clarity and accountability regarding who was responsible for ensuring the dietary staff had the necessary certifications. The ADM noted that the facility did not have a policy regarding food handler's certificates and attributed the oversight to transitions in management and ownership. The absence of the certificate meant DA A was not trained in proper food safety protocols, potentially affecting all residents who consumed food from the kitchen.
Facility Fails to Maintain Safe Wheelchair Equipment
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition, specifically for a resident who used a wheelchair as a mobility device. The resident, who had Alzheimer's disease and other mobility-related diagnoses, was observed self-propelling in a wheelchair with a loose brake handle. This issue was identified during an observation and interview with a CNA, who acknowledged the risk of falls associated with a malfunctioning wheelchair brake. The CNA had not previously noticed the loose brake handle and took steps to notify the maintenance supervisor. The maintenance supervisor confirmed the issue with the wheelchair brake handle and stated that he was responsible for the maintenance of residents' wheelchairs, relying on staff to report any issues. Interviews with other staff, including an LPN and the DON, revealed that while maintenance was responsible for repairs, staff were expected to inspect wheelchairs and report any problems. Despite these expectations, the facility did not provide a policy outlining maintenance responsibilities, even after multiple requests from the surveyor.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
