The Villages Of Dallas
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 550 E Ann Arbor Ave, Dallas, Texas 75216
- CMS Provider Number
- 675611
- Inspections on file
- 40
- Latest survey
- September 9, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at The Villages Of Dallas during CMS and state inspections, most recent first.
Three residents with cognitive impairment and total assistance needs were found with their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff and nursing leadership confirmed the expectation for call lights to be within reach, but observations showed this was not consistently followed.
A resident identified as a fall risk was provided with a bolster mattress as a safety intervention without a physician order. The equipment was included in the care plan, but the DON acknowledged that obtaining the necessary physician order was overlooked, contrary to facility policy requiring such authorization for restraint use.
A resident with vascular dementia and coordination issues experienced a fall that was not promptly documented or reflected in their care plan. The responsible nurse failed to complete a fall assessment on the day of the incident, leading to a delay in updating the care plan. The ADON had to document the incident five days later, highlighting a lapse in communication and adherence to facility policies requiring timely updates to care plans after falls.
A resident with vascular dementia and a history of falls was found on the floor twice, with the fall mat improperly placed under the bed. The facility failed to provide adequate supervision and did not follow its fall management policy, as no assessment or documentation was completed after the incidents.
The facility failed to maintain effective infection control practices during incontinent care for three residents. CNAs did not perform proper hand hygiene or change gloves appropriately, risking cross-contamination and infection. Interviews confirmed these lapses, emphasizing the need for adherence to infection prevention protocols.
A resident with severe cognitive impairment and a pressure ulcer on the right foot did not receive proper wound care. The LVN cleaned the surrounding skin before the wound itself, using the same gauze, contrary to the facility's policy and professional standards. This improper technique could introduce contaminants into the wound, increasing infection risk. Interviews with staff confirmed the deficiency in wound care practices.
A facility failed to provide proper incontinent care for a resident with acute kidney failure, risking urinary tract infections. A CNA was observed wiping the resident's perineal area from back to front, contrary to the recommended front-to-back method. The CNA acknowledged the mistake, and the DON and ADON confirmed the correct procedure to prevent infection.
A resident with severe cognitive impairment was left with medications unattended by a medication aide, contrary to facility policy. The resident, diagnosed with hypertension, GERD, and cerebral infarction, was observed with a pill left on her table, and the aide admitted to not monitoring the administration. Interviews with the DON, ADON, and Administrator confirmed that medications should not be left with residents due to risks, highlighting a failure to follow procedures.
A resident with a history of osteoarthritis and hemiplegia was injured due to the facility's failure to provide adequate supervision and assistive devices during a transfer. The staff did not follow the No Lift policy, resulting in a fracture after an inappropriate manual lift. The facility did not obtain accurate transfer information from the previous facility, and staff failed to conduct their own assessments, leading to the incident.
The facility failed to maintain a clean and sanitary environment in six resident rooms, with observations of dirt and stains in bathrooms, air conditioning units, and mini fridges. Housekeeping staff lacked proper tools for cleaning, and the supervisor admitted to inadequate cleaning practices, contrary to facility policies.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff not adhering to hand hygiene protocols during resident care. A CNA did not change gloves or sanitize hands during incontinent care, and an LVN brought a container with medical supplies into multiple residents' rooms, risking cross-contamination. Additionally, two CNAs did not perform hand hygiene after removing soiled gloves. These actions were acknowledged by staff and facility leadership as deficiencies.
The facility failed to ensure that the call light system was accessible for two residents, one with muscle weakness and Alzheimer's, and another with blindness and cognitive impairment. Both residents were found with their call lights out of reach, contrary to their care plans and facility policy, which require call lights to be within reach to ensure residents can request assistance.
A resident with chronic pain was prescribed hydrocodone-acetaminophen, but a pill was left unattended on the nightstand, which the resident forgot to take. The LVN confirmed the medication was not administered as required, posing a risk of improper medication use. The facility's policy mandates that medications be administered within prescribed time frames, which was not followed.
The facility failed to ensure that call lights were within reach for three residents, each with significant medical conditions and cognitive impairments. Observations revealed that call lights were either on the floor or clipped to a pillow, making them inaccessible. Staff interviews confirmed the importance of accessible call lights for resident safety, yet the facility did not adhere to its policies, resulting in this deficiency.
A resident with severe cognitive impairment and a history of falls did not have a fall mat placed beside their bed as required. The mat was found folded in a bag against the wall, contrary to the care plan that ordered a low bed and floor mat. Staff interviews revealed a lack of awareness and documentation in the care plan, contributing to the oversight.
A facility failed to implement comprehensive care plans for two residents, leading to a serious incident. One resident with severe cognitive impairment wandered into another's room and was attacked, resulting in a head injury. The care plans lacked interventions for the wandering and aggressive behaviors, contributing to the incident. Staff interviews revealed a lack of communication and oversight in updating care plans, which were not revised as required.
A resident with severe cognitive impairment was physically attacked by another resident with a history of aggression, resulting in a serious head injury. The facility failed to have interventions in place to manage the aggressive resident's behaviors, despite previous incidents and staff awareness of his tendencies. This oversight in care planning led to the deficiency identified in the report.
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days during a 6-month review period. Interviews with the DON, CNA/Staffing Coordinator, and Administrator revealed a lack of awareness and communication regarding the missed RN hours, placing residents at risk of receiving higher levels of patient care without adequate RN oversight.
The facility failed to ensure proper food storage, preparation, and sanitation in both the main kitchen and sub-kitchen. Observations revealed incorrectly dated food, dirty storage bins, and unsanitary conditions in the sub-kitchen. Staff interviews indicated confusion about cleaning responsibilities, and the facility's policies were not being followed.
The facility failed to ensure the call light system was accessible for four residents, placing them at risk of being unable to obtain assistance. Residents struggled to reach their call lights, which were not placed within their reach as required by their care plans. Staff acknowledged the importance of call lights and the potential risks if they are not accessible.
The facility failed to provide a safe, clean, and homelike environment for 11 residents, with observations revealing uncleanliness and inconsistencies in cleaning responsibilities. Interviews with staff highlighted gaps in the cleaning processes, and the Administrator acknowledged recent challenges due to a COVID outbreak.
The facility failed to provide proper respiratory care by not storing nebulizer masks correctly, having incomplete oxygen administration orders, and not changing oxygen concentrator tubing weekly as scheduled. These deficiencies were observed and confirmed through interviews and record reviews.
A facility failed to maintain a resident's wheelchair, which had a missing right armrest cushion and a torn left armrest cushion. The CNA responsible for the resident did not notice or report the damage, and other staff members, including the LVN, DON, and Occupational Therapist, were unaware of the issue. The facility lacked a specific policy for reporting and maintaining wheelchair damage.
A resident with an indwelling catheter was observed with her catheter bag visibly hanging under her wheelchair without a privacy bag, contrary to facility policy. Staff acknowledged the oversight, and the DON and Administrator confirmed the importance of using a privacy bag to maintain the resident's dignity.
A resident with an indwelling urinary catheter was observed with the catheter bag touching the floor, contrary to care plan and physician orders. Staff interviews confirmed awareness of the risk of infection but revealed lapses in consistent implementation of proper catheter care practices.
A facility failed to ensure continuous enteral feeding for a resident with a G-tube, resulting in a three-hour gap in feeding due to a lack of supplies and unclear downtime orders. The DON and Administrator acknowledged the need for clear and consistent feeding schedules.
The facility failed to document wound care treatments and pain assessments for a resident with a pressure ulcer. The resident's medical records showed gaps in documentation, and staff did not follow required procedures, which could lead to exacerbation of the wound or infection.
The facility failed to maintain an Infection Prevention and Control Program, leading to deficiencies involving a CNA not changing gloves or performing hand hygiene during incontinence care and a Dietary Manager not wearing a face mask in the kitchen during a COVID outbreak. These actions could place residents at risk of cross-contamination and infection.
Call Lights Not Accessible to Residents Requiring Total Assistance
Penalty
Summary
The facility failed to ensure that call light systems were accessible to residents who required total assistance and were identified as fall risks. During observations, three residents with moderate to severe cognitive impairment and significant physical limitations were found with their call lights out of reach. One resident's call light was under the bed, another's was approximately three feet away from the bed, and a third resident's call light was hanging behind the bed frame. These residents' care plans specifically included interventions to keep call lights within reach and encourage their use. Staff interviews confirmed that call lights were not always placed within reach, despite facility policy and care plan requirements. Certified nursing assistants and licensed vocational nurses acknowledged the importance of call light accessibility and stated that staff were expected to check rooms regularly to ensure compliance. The Director of Nursing also confirmed that call lights should be within reach and that measures such as clips had been implemented to help maintain their placement. However, on the day of the survey, the call lights for these residents were not accessible, contrary to both policy and individualized care plans.
Failure to Obtain Physician Order for Bolster Mattress Used as Restraint
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints not required to treat medical symptoms. Specifically, a bolster mattress was placed on the resident's bed as an intervention for fall risk, but there was no physician order authorizing its use. The resident's care plan included the bolster mattress for safety, and the Director of Nursing acknowledged that the equipment was provided due to the resident's fall risk and that it was her responsibility to obtain a physician order, which she failed to do. Record review showed that the resident had diagnoses including unsteadiness on feet and repeated falls, required extensive assistance with activities of daily living, and was unable to complete a BIMS interview. Observations confirmed the presence of the bolster mattress, and interviews with facility staff confirmed that the required physician order was missing. Facility policy requires physician notification and adherence to state regulations when restraints are used, but this process was not followed in this case.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team following a recent fall. The resident, who has vascular dementia, lack of coordination, and muscle weakness, experienced a fall on 03/08/2025, which was not documented in the care plan. The resident's care plan did not reflect this incident, and the fall assessment was not completed by the responsible nurse on the day of the fall. Instead, a late entry was made by the Assistant Director of Nursing (ADON) five days later, indicating a delay in documentation and assessment. Interviews with staff revealed that the incident was not communicated promptly, and the necessary documentation was not completed in a timely manner. The ADON only became aware of the fall two days after it occurred and had to complete the documentation himself due to the initial nurse's failure to do so. The facility's policies require that care plans be updated after each fall, and the lack of timely updates could potentially result in residents not receiving the most efficient care. The facility's Care Planning and Fall Management System policies emphasize the importance of timely documentation and care plan updates to ensure appropriate care for residents.
Failure to Ensure Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision was provided to prevent accidents. Specifically, the facility did not ensure that a fall mat was properly placed on the floor next to the resident's bed, as evidenced by a photo showing the resident lying on the bare floor with the fall mat underneath the bed. This oversight was noted for a resident with vascular dementia, lack of coordination, and muscle weakness, who had a history of falls without injury. The resident's care plan indicated a risk for falls due to decreased mobility and impaired cognition, with interventions including keeping the bed in the lowest position and placing a fall mat on the floor. However, on the day of the incident, the resident was found on the floor twice, with the fall mat not properly positioned. Interviews with staff revealed that the fall mat was folded and placed in the corner when the resident was not in bed, and the resident was unable to walk or transfer herself, indicating a lack of proper supervision and adherence to the care plan. The facility's policy required a physical assessment and documentation in the medical record following a fall, but the nurse involved did not complete these tasks, as there were no injuries. The incident was categorized as an unwitnessed fall, and the lack of documentation and assessment was acknowledged by the facility's administration. The facility's policies on fall management and response to significant changes in condition were not followed, contributing to the deficiency.
Inadequate Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and glove use during incontinent care for three residents. Resident #58, a female with a urinary tract infection and moderate cognitive impairment, was observed receiving care from CNA B, who did not sanitize her hands before donning new gloves from her pocket and failed to change gloves after cleaning the resident's bottom before handling a new brief. Similarly, Resident #45, a male with severe cognitive impairment and muscle weakness, received care from CNA B and CNA C. Both CNAs failed to perform hand hygiene between glove changes, and CNA C did not change gloves after handling soiled materials. CNA B admitted to not sanitizing her hands between glove changes and acknowledged the risk of infection from such practices. Resident #42, a female with acute kidney failure, was also subject to improper infection control practices. CNA D did not sanitize her hands between glove changes and failed to change gloves after cleaning the resident's perineal area before adjusting the brief. Interviews with the CNAs and facility leadership confirmed the lapses in protocol, highlighting the risk of cross-contamination and infection due to inadequate hand hygiene and glove use.
Improper Wound Care Technique for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound care practices. The resident, an elderly male with severe cognitive impairment and a history of sepsis and muscle weakness, had a pressure ulcer on his right foot. The care plan required specific wound care procedures, including cleaning the wound with normal saline, applying collagen, and covering it with a dry dressing. However, during an observation, it was noted that the Licensed Vocational Nurse (LVN) did not follow the correct procedure for cleaning the wound. The LVN was observed cleaning the surrounding skin of the wound before the wound itself, using the same gauze for both areas, which is contrary to professional standards. The correct procedure, as outlined in the facility's policy, requires cleaning from the least contaminated area (the wound) to the most contaminated area (the surrounding skin) and using a new piece of gauze for each stroke to prevent contamination. The LVN's actions could potentially introduce contaminants from the surrounding skin into the wound, increasing the risk of infection. Interviews with the LVN, the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) confirmed the improper wound care technique. The DON acknowledged that the wound should be cleaned from the inside out, and the gauze should be changed with each stroke to avoid contamination. The ADON reiterated the importance of removing debris, bacteria, and exudate from the wound to reduce infection risk. The facility's policy also supports this method, emphasizing the need to wash from the center of the wound to the periphery, from the least to the most contaminated area.
Improper Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infections. The incident involved a cognitively intact female resident with acute kidney failure, who was always incontinent of bowel and bladder. During an observation, a CNA was seen cleaning the resident's perineal area incorrectly by wiping from back to front, which is against the recommended practice of wiping from front to back to prevent cross-contamination and infection. The CNA admitted to wiping incorrectly due to the resident's position but acknowledged the importance of following the correct procedure regardless of the resident's position. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the proper procedure should always be from front to back to avoid infection. The facility's policy also supports this practice, emphasizing washing from the cleanest to the dirtiest area to prevent irritation or infection.
Failure to Monitor Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was provided with medications and pharmaceutical services in accordance with their needs. Specifically, the medication aide (MA) left the resident's medications inside the resident's room without monitoring the administration of the medications. This occurred despite the resident having a severe cognitive impairment, as indicated by a BIMS score of 00, and no assessment for self-administration of medications was documented. The resident, who was diagnosed with hypertension, gastro-esophageal reflux disease, and cerebral infarction, was observed with a plastic cup containing a white, round pill on her overbed table. The resident mentioned that she had already taken two out of three pills left by the staff and intended to take the remaining pill shortly. The MA admitted to leaving the medications with the resident because the resident preferred to take them every five minutes, acknowledging that she should have stayed with the resident until all medications were taken. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator confirmed that staff should not leave medications with residents due to the risk of choking, not taking the medications, or potential overdose. The facility's policy requires that medications be administered as prescribed and not left unattended with residents, highlighting a failure to adhere to these procedures in this instance.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were provided to prevent accidents, specifically for a resident who required a mechanical lift for transfers. The staff did not adhere to the facility's No Lift policy, which mandates the use of a total mechanical lift for individuals who can bear weight on their legs but require minimal assistance. This failure resulted in the resident experiencing uncontrolled pain and being diagnosed with a right distal tibial spiral fracture after an inappropriate transfer. The resident, who had a history of osteoarthritis, hemiplegia, and a previous knee replacement, was admitted to the facility with a need for moderate assistance from one or two persons due to left-sided hemiplegia. Despite this, the facility did not obtain accurate transfer status information from the referring facility prior to admission. During the transfer, a staff member attempted to lift the resident manually, ignoring requests from the resident and her family to use a mechanical lift, leading to the resident's injury. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's transfer needs. The staff relied on incomplete or inaccurate information from the previous facility and did not conduct their own assessments to determine the appropriate level of assistance required. This oversight, combined with the staff's failure to listen to the resident's and her family's concerns, contributed to the incident and the resident's subsequent injury.
Facility Fails to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in six out of ten rooms reviewed. Observations revealed that the bathrooms had built-up dirt particles along the walls, and the bases of the toilets had thick brownish stains. The air conditioning units in the rooms were found with dirt stains on top and thick black dirt between the vents. Additionally, mini fridges in some rooms had noticeable stains, indicating a lack of thorough cleaning and sanitization. Interviews with housekeeping staff and the supervisor confirmed that the cleaning procedures were not adequately followed. The housekeeping staff admitted to not having the proper tools to clean the air conditioning vents and mentioned that the base of the toilets appeared rusty. The housekeeping supervisor acknowledged the deficiencies and stated that deep cleaning was scheduled once a week, but the mini fridges were not regularly cleaned unless visibly dirty. The facility's policies on cleaning and disinfection were not adhered to, potentially posing health risks to the residents.
Infection Control Deficiencies in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in several deficiencies related to hand hygiene and the handling of medical equipment. During an observation, a CNA providing incontinent care to a resident did not perform hand hygiene before putting on gloves, nor did she change gloves or sanitize her hands after handling soiled items and before touching clean items. This lapse in protocol was acknowledged by the CNA, who admitted that hand hygiene is crucial to prevent the spread of germs. Another deficiency was observed with an LVN who brought a plastic container containing lancets, test strips, and alcohol wipes into the rooms of multiple residents while checking their blood sugar levels. The LVN placed the container on residents' beds and tables, which could lead to cross-contamination. Additionally, the LVN did not wear gloves while administering insulin injections, further increasing the risk of infection transmission. The LVN recognized the potential for cross-contamination and acknowledged the importance of hand hygiene and proper glove use. A similar issue was noted with two CNAs providing incontinence care to another resident. They failed to perform hand hygiene after removing soiled gloves and before putting on new ones. Both CNAs admitted the importance of hand hygiene in preventing contamination and infection. Interviews with facility leadership, including the DON and ADON, confirmed that staff are expected to follow hand hygiene protocols to minimize infection risks, and they acknowledged the deficiencies observed during the survey.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light system in the rooms of two residents was accessible, which is a deficiency in accommodating the needs and preferences of residents. Resident #6, an elderly female with muscle wasting, muscle weakness, and unsteadiness, was found in her bed unable to locate her call light, which was pressed between the mattress and the bed frame. This resident required substantial assistance for personal hygiene, toileting, and showering, and her care plan specifically noted the importance of having the call light within reach due to her risk of falls related to Alzheimer's disease. Similarly, Resident #7, an elderly male diagnosed with muscle weakness, unsteadiness, and blindness, was found with his call light hanging on the wall, out of reach. This resident had a severe cognitive impairment and required substantial assistance with daily activities. His care plan also emphasized the need for the call light to be within reach due to his risk of falls. During observations, the resident was unable to indicate the location of his call light, highlighting the inaccessibility of the device. Interviews with staff, including a CNA, the DON, the Administrator, and the ADON, confirmed the importance of call lights as a means of communication for residents to request assistance. The facility's policy, revised in 2007, mandates that call devices be placed within residents' reach before staff leave the room. However, the failure to adhere to this policy resulted in the call lights being inaccessible to the residents, potentially compromising their ability to obtain assistance when needed.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident, specifically for one resident who was reviewed for pharmaceutical services. The resident, who was cognitively intact and had a history of chronic venous insufficiency, chronic osteomyelitis, and localized swelling in the left leg, was prescribed hydrocodone-acetaminophen for chronic pain. An observation revealed that a white oblong pill was left in a medicine cup on the resident's nightstand, which the resident had not taken. The resident stated that the nurse had left the pill the previous evening, and she forgot to take it. A CNA found the pill on the resident's chest and placed it back in the medicine cup on the nightstand. The LVN, upon being notified, confirmed that the pill was hydrocodone-acetaminophen and stated that it should not have been left in the room. The LVN disposed of the pill in the sharps container and reported the incident to the ADON. The LVN expressed concern that a confused resident could have mistakenly ingested the pill, highlighting the importance of ensuring residents take their medication in the presence of a nurse to prevent choking or other issues. The DON acknowledged that the night nurse should have observed the resident taking the medication before leaving the room. The facility's policy on drug administration requires medications to be administered within prescribed time frames, which was not adhered to in this instance.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents' call lights were within reach, compromising their ability to call for assistance. This deficiency was observed in three residents, each with significant medical conditions and cognitive impairments. Resident #1, with severe cognitive impairment and multiple health issues, had his call pad on the floor under his bed, making it inaccessible. Similarly, Resident #2, who was severely cognitively impaired and had an indwelling catheter, also had his call button on the floor, out of reach. Resident #3, with mild cognitive impairment and total dependence for personal care, had his call button clipped to a pillow, which was not accessible from his wheelchair. Interviews with staff, including the Administrator in Training, LVN, CNA, ADON, and DON, revealed a consensus that call lights should be within reach of residents to ensure their safety and ability to call for assistance. Staff acknowledged the importance of this practice, noting that failure to provide accessible call lights could lead to residents attempting to meet their own needs, potentially resulting in falls and injuries. Despite this understanding, observations indicated that the call lights for Residents #1, #2, and #3 were not placed within their reach, highlighting a lapse in adherence to facility policies. The facility's policies on call lights and resident safety clearly state that call devices should be placed within residents' reach and that room checks should be conducted routinely to ensure safety and quality of life. However, the observations and interviews suggest that these policies were not consistently followed, leading to the deficiency. The lack of accessible call lights for these residents represents a failure to accommodate their needs and preferences, as outlined in their comprehensive care plans.
Failure to Ensure Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, the facility did not place a fall mat on the floor next to the bed of a resident who was at risk for falls. The resident, who had severe cognitive impairment and required extensive assistance with daily activities, had a history of falls and was ordered to have a low bed and floor mat as part of his care plan. However, during an observation, the fall mat was found folded in a plastic bag against the wall instead of being placed beside the bed. Interviews with staff revealed a lack of awareness and adherence to the resident's care plan. The LVN acknowledged that the resident was at risk of injury without the fall mat in place, and the CNA was unsure why the mat was not positioned correctly. The DON admitted that the fall mat was not documented in the care plan, which contributed to the oversight. The facility's policy required routine room checks to ensure resident safety, but this was not effectively implemented, leading to the deficiency.
Failure to Implement Comprehensive Care Plans Leads to Resident Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which resulted in a serious incident. Resident #1, who had severe cognitive impairment due to dementia and a history of traumatic brain injury, did not have interventions in place to address his wandering behavior. On June 5, 2024, Resident #1 wandered into another resident's room and was physically attacked, resulting in a serious head injury. The care plan for Resident #1 was not updated to include measures to prevent such incidents, despite his known wandering tendencies. Resident #2, who had intact cognition but exhibited aggressive behaviors, also lacked a comprehensive care plan addressing his potential for physical aggression. Despite previous incidents of combative behavior, interventions were not documented in his care plan until after the incident with Resident #1. The facility's failure to document and implement appropriate interventions for Resident #2's aggressive behavior contributed to the incident where he pushed Resident #1, causing a serious injury. Interviews with facility staff revealed that there was a lack of communication and oversight in updating care plans to reflect changes in residents' conditions and behaviors. The MDS Coordinator and DON acknowledged that care plans were not updated as required, which led to improper care being provided. The facility's policy required care plans to be reviewed and revised quarterly or as needed with changes in condition, but this was not adhered to, resulting in the deficiency.
Failure to Prevent Resident Abuse Due to Inadequate Care Planning
Penalty
Summary
The facility failed to protect a resident from abuse, resulting in an incident where one resident was physically attacked by another. The resident who was attacked had severe cognitive impairment and a history of traumatic brain injury, which made him vulnerable. On the day of the incident, the resident wandered into another resident's room and was pushed, leading to a serious head injury. The facility did not have interventions in place to prevent such aggressive behavior from the resident who attacked, despite his history of aggression. The resident who committed the attack had a history of dementia and poor impulse control, yet his care plan lacked interventions to manage his aggressive behaviors until after the incident occurred. Prior to the incident, there were no documented interventions to address his aggression, even though he had previously exhibited aggressive behavior towards other residents. The facility's staff were aware of his tendency to become upset when others entered his room, but no effective measures were in place to prevent such incidents. Interviews with staff and family members revealed that the facility was aware of the aggressive resident's behaviors and the potential for harm, yet failed to implement necessary interventions. The Director of Nursing and other staff acknowledged the oversight in care planning, which contributed to the incident. The facility's failure to update and implement appropriate care plans for residents with aggressive behaviors directly led to the deficiency identified in the report.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 5 days during the 6-month review period. Specifically, the facility did not have the required RN coverage on Saturdays and Sundays for 5 days between July 2023 and December 2023. The dates with insufficient RN coverage included 11/04/23, 11/25/23, 12/02/23, 12/09/23, and 12/16/23, with recorded hours ranging from 1.15 to 3.4 hours. This deficiency placed residents at risk of receiving higher levels of patient care without adequate RN oversight. Interviews with the Director of Nursing (DON) and the CNA/Staffing Coordinator revealed a lack of awareness and communication regarding the missed RN hours. The DON stated she was unaware of any missed RN hours and believed she had covered any shortages. However, the dates she provided did not match the dates with insufficient coverage. The CNA/Staffing Coordinator also believed there were no concerns with RN coverage and stated that the DON usually covered any shortages. The Administrator was also unaware of the lapse in RN coverage and stated he would follow up with the DON. The facility's policy on RN coverage, which requires an RN to provide services for at least 8 consecutive hours a day, 7 days a week, was not adhered to during the review period.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed that a gallon container of sweet relish in the walk-in refrigerator was incorrectly dated, and large white bins containing sugar, flour, and thickener had dried food particles and blackish stains. Additionally, the sub-kitchen on the skilled nursing floor had stained counters and walls, and the refrigerator contained undated food items and staff food, with the door not closing properly. The ice machine also had dirt and rust stains, indicating a lack of proper sanitation. Interviews with staff revealed confusion and lack of clarity regarding responsibilities for cleaning and maintaining the kitchen areas. The Dietary Manager admitted to ongoing issues with staff not cleaning the bins properly and stated that the risk of these concerns could result in food-borne illnesses. The CNA/Staffing Coordinator and LVN provided conflicting information about who was responsible for cleaning the refrigerators and other kitchen equipment, indicating a lack of clear protocols and communication among staff. The Housekeeping Supervisor acknowledged the unacceptable condition of the kitchen areas and attributed it to new staff still learning their roles. The Administrator confirmed that a new staff member had been hired to manage nourishment snacks and clean the sub-kitchens but did not comment on the potential impact on residents. The facility's policy on food storage and supplies, dated 2012, was not being followed, as evidenced by the observations and staff interviews. The FDA Code also mandates proper labeling and protection of food from contamination, which the facility failed to adhere to.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure the call light system in the rooms of four residents was accessible, which could place them at risk of being unable to obtain assistance when needed. Resident #97, a male with muscle weakness and cognitive impairment, struggled to find his call light, which was hanging lower than the bed. He had to twist and search for two minutes to locate it, indicating it was not placed within his reach as required by his care plan. This resident had a history of falls and required extensive assistance for daily activities. Resident #49, a male with low back pain and muscle weakness, was found sitting on a chair with his call light placed on a side table on the opposite side of the bed. The CNA acknowledged forgetting to place the call light within the resident's reach after assisting him to transfer from bed to chair. This oversight could lead to the resident falling while trying to reach the call light. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene. Resident #60, a female with a history of falling and muscle weakness, was observed sitting in her wheelchair with her call light on the floor under the bed. She was unable to see or reach her call light, which was confirmed by both the resident and staff. The DON and other staff members acknowledged the importance of call lights for residents to communicate their needs and the potential risks if call lights are not accessible. Despite recent in-service training on proper call light placement, the facility failed to ensure compliance, leading to this deficiency.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 11 residents. Observations revealed multiple instances of uncleanliness, including brownish stains on walls, dirt on air-condition units, and stained bedside tables. Specific rooms had issues such as scrape marks on walls, dirt particles on shelves, and stained toilets, indicating a lack of proper cleaning and maintenance. Interviews with staff, including a CNA/Staffing Coordinator, the DON, and the Housekeeping Supervisor, revealed that there were inconsistencies in the cleaning responsibilities and processes. The CNA/Staffing Coordinator mentioned that she would notify housekeeping and the nurse on duty when rooms were dirty, but there was uncertainty about who was responsible for cleaning mini fridges. The DON stated that the ADON was required to observe residents' rooms daily, but leadership did not conduct regular rounds to check rooms. The Housekeeping Supervisor admitted that she could not perform audit checks as often as needed due to other responsibilities. The Administrator acknowledged the concerns and mentioned that the facility had recently dealt with a COVID outbreak, which diverted attention to other areas. The Plant Manager and Housekeeping Supervisor provided details on the cleaning protocols, but it was evident that these were not consistently followed. The facility's policy on Environmental Services outlined the need for a clean and safe environment, but the observed conditions did not meet these standards, leading to potential infection control issues and a decreased quality of life for the residents.
Deficiencies in Respiratory Care
Penalty
Summary
The facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not properly store nebulizer masks for two residents, did not have a clear order for oxygen administration for one resident, and did not change the oxygen concentrator tubing weekly as scheduled for two residents. These deficiencies were observed during a survey and confirmed through interviews and record reviews. Resident #2's nebulizer mask was found inside a drawer on top of an incontinent brief and was not bagged, which could lead to infections. Similarly, Resident #99's nebulizer mask was found inside a drawer touching the top of the nebulizer machine and was also not bagged. Interviews with the LVNs confirmed that the masks should have been bagged when not in use to prevent infections. Resident #34 had incomplete physician orders for oxygen administration, lacking the specific rate and route of administration. This oversight was acknowledged by the LVN, who stated that the incomplete orders could result in confusion and unmet respiratory needs. Additionally, the tubing for the oxygen concentrators of Resident #23 and Resident #41 was not changed weekly as scheduled, with dates on the tubing indicating they had not been replaced as required. The DON and Administrator confirmed the importance of proper storage and complete orders for respiratory care equipment and procedures.
Failure to Maintain Wheelchair and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and maintenance of assistive devices for Resident #6, who has severe cognitive impairment and requires a three-person assist for all transfers. The resident's wheelchair was found to be in poor condition, with a missing right armrest cushion and a torn left armrest cushion. This issue was not reported by the CNA responsible for the resident's care, who admitted to not noticing the damage until it was pointed out by the surveyor. Further interviews revealed that the LVN, DON, and other staff members were unaware of the wheelchair's condition. The CNA was expected to report such damages to the charge nurse and document it in the resident's chart, but this did not occur. The LVN stated that the maintenance or therapy department would be responsible for repairs if the issue was reported through the TELS system, but no such report was made. The facility lacked a specific policy for reporting and maintaining wheelchair damage. The Occupational Therapist and Maintenance Director also confirmed that they were not aware of the issue, as it had not been reported to them. The Administrator stated that either the therapy or maintenance department would handle such repairs if reported, but he did not believe the missing or torn armrest cushions posed a risk to the resident.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not providing a privacy bag for her catheter bag. The resident, an elderly female with an indwelling catheter, was observed in her wheelchair with the catheter bag visibly hanging under the seat without a privacy bag. This was confirmed by multiple staff members, including an LVN and a CNA, who acknowledged the oversight and the potential for embarrassment to the resident. The Director of Nursing (DON) and the Administrator also confirmed that the catheter bag should have been covered with a privacy bag to maintain the resident's dignity. The facility's policy on indwelling urinary catheter care explicitly states that a privacy bag should be used to cover the drainage bag. Despite this policy, the staff failed to adhere to the procedure, resulting in a deficiency in maintaining the resident's dignity and quality of life.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received proper care to prevent urinary tract infections. Specifically, the catheter bag of a cognitively intact female resident was observed touching the floor while she was in her wheelchair. This observation was made despite the resident's care plan indicating that catheter care should be provided every shift and physician orders specifying that the catheter bag should be positioned below the level of the bladder but off the floor. Interviews with the LVN, CNA, and DON confirmed that the catheter bag touching the floor could lead to infections and that it was the staff's responsibility to ensure the catheter bag was properly positioned. The resident's catheter bag was found touching the floor during an observation, and subsequent interviews revealed that the staff were aware of the importance of keeping the catheter bag off the floor but failed to consistently implement this practice. The CNA admitted to not noticing the catheter bag touching the floor, and the LVN acknowledged the issue and took corrective action by changing the catheter bag and reminding the CNA. The DON emphasized that all staff were responsible for ensuring proper catheter care and mentioned plans to remind staff through an in-service. The facility's policy on indwelling urinary catheter care also highlighted the importance of maintaining hygiene and preventing infection, which was not adhered to in this instance.
Failure to Maintain Continuous Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not maintain continuous feeding through a gastrostomy tube (G-tube) as ordered for Resident #2. The resident's feeding formula was found to be empty, and the feeding pump was off for a three-hour gap, contrary to the physician's order for continuous feeding with a specified downtime. The Licensed Vocational Nurse (LVN) responsible for the resident's care acknowledged the gap and cited a lack of necessary supplies as the reason for the interruption. Additionally, there was no clear and complete order for the downtime, leading to potential confusion among the nursing staff about when to stop and resume feeding. The Director of Nursing (DON) confirmed that the order for continuous feeding should have no gaps except for the specified downtime and that the downtime should be clearly stated in the order. The DON admitted responsibility for monitoring the orders and ensuring compliance. The Administrator also acknowledged the need for coordination with clinicians to ensure that the feeding schedule is clear and adhered to. The facility's policies on gastrostomy tube care and physician orders were reviewed, indicating that orders must include specific details such as quantity, duration, dosage, and frequency, which were not adequately followed in this case.
Failure to Document Wound Care Treatments and Pain Assessments
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practice for a resident with a pressure ulcer. Specifically, the facility did not document wound care treatments and pain assessments during wound care treatments for the resident. The resident, an elderly female with a pressure ulcer on the sacral region, had a physician's order for daily wound care treatment. However, the treatment was not documented on two specific dates, and pain assessments were not recorded before, during, or after the wound care on those dates. Interviews with the LVN and DON confirmed that the treatments were either not performed or not documented, which is against the facility's policy and could lead to exacerbation of the wound or infection. The resident's medical records showed that she was cognitively intact and had a comprehensive care plan indicating the need for daily wound care to promote healing and prevent infection. Despite this, the administrative record revealed gaps in documentation, and the staff responsible for wound care did not follow the required procedures. The DON acknowledged the importance of daily treatment for proper wound healing and confirmed that the lack of documentation indicated that the treatments were not done. The administrator also expected the staff to follow the orders and best practices for wound care, although he was not familiar with the specific procedures.
Infection Control Deficiencies in Hand Hygiene and Face Mask Usage
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, leading to two specific deficiencies. The first deficiency involved a Certified Nursing Assistant (CNA) who did not change her gloves or perform hand hygiene while providing incontinence care to a resident. The resident, a cognitively intact male with chronic respiratory failure and chronic obstructive pulmonary disease, required extensive assistance for daily activities. During the care, the CNA failed to change her gloves after cleaning the resident's buttocks and before handling a clean brief, which she acknowledged could cause contamination and infection. The Director of Nursing (DON) confirmed that the gloves should have been changed to prevent cross-contamination and infection, emphasizing the importance of hand hygiene and glove changes during such procedures. The second deficiency involved the Dietary Manager (DM), who was observed not wearing a face mask while in the kitchen preparing food, despite a facility-wide requirement due to a recent COVID outbreak. The DM acknowledged that all kitchen staff were required to wear face masks to prevent the spread of infection. The Administrator also confirmed that all staff were expected to wear face masks at all times, especially in the kitchen, to prevent residents from getting sick. The facility's policy on infection control and hand hygiene, revised in October 2022, mandates that healthcare workers perform hand hygiene based on accepted standards, including washing hands with soap and water when visibly soiled. The failure to adhere to these policies and procedures by both the CNA and the DM could place residents at risk of cross-contamination and infection, as noted in the observations and interviews conducted during the survey.
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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