The Villages On Macarthur
Inspection history, citations, penalties and survey trends for this long-term care facility in Irving, Texas.
- Location
- 3443 N Macarthur Blvd, Irving, Texas 75062
- CMS Provider Number
- 676358
- Inspections on file
- 43
- Latest survey
- January 2, 2026
- Citations (last 12 mo.)
- 36
Citation history
Health deficiencies cited at The Villages On Macarthur during CMS and state inspections, most recent first.
Two residents were found without adequate access to the call light system—one had no call light cord in his room, and another could not reach her call light because it was tied to the bed while she was in her wheelchair. Staff were unaware of these issues, and both residents had to rely on alternative means to request assistance. Facility policy requires call lights to be within easy reach at all times.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A working call system was not available in each resident's bathroom and bathing area, as observed during the survey. This deficiency was cited due to the lack of a functional system for residents to request assistance in these areas.
A deficiency was cited when a resident’s drug regimen included medications that were not clinically indicated or were excessive, and the facility did not ensure the regimen was free from unnecessary drugs.
A Dietary Aide did not follow the prescribed recipe for preparing a pureed meal, using gravy instead of beef broth and failing to achieve the required smooth texture. The Dietary Manager confirmed the recipe was not followed, resulting in a pureed meal that lacked proper flavor and consistency for residents on pureed diets.
A resident with quadriplegia and contractures was unable to use the temporary call bell provided during a facility-wide call light system outage, leaving her without a reliable means to contact staff for assistance. Staff and nursing leadership were aware of the resident's inability to use the bell, and the care plan required accessible call devices, but no suitable alternative was initially provided.
A resident with multiple mental health diagnoses was discharged without a completed interdisciplinary discharge summary, missing essential sections such as recapitulation of stay, physician signature, and summaries from social services, activities, and therapy. Nursing notes documented the resident's departure against medical advice, and staff interviews confirmed that required documentation was not completed or verified by the responsible departments.
A resident with severe cognitive impairment and multiple mental health diagnoses, including a new diagnosis of schizophrenia, was not referred for a required PASRR assessment after the new diagnosis. The responsible MDS nurse did not complete the necessary screening or notify others, and the facility lacked a specific PASRR policy, relying instead on state guidelines.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs for support with basic daily functions.
A resident with COPD and other chronic conditions was observed receiving oxygen at 3 L/min instead of the ordered 2 L/min. The resident and staff were unaware of who authorized the increase, and there was no documentation or physician order for the change. Nursing staff and the DON confirmed that oxygen levels should be checked and maintained as ordered, but this was not done, resulting in a deficiency in respiratory care.
Two residents receiving pain management medications did not have accurate narcotic counts or proper documentation on the medication cart. A nurse administered morphine and oxycodone but failed to sign the narcotic log as required. Both the ADON and DON could not confirm recent audits of medication carts, and no training records on narcotic administration were available, despite facility policy requiring immediate documentation.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A deficiency was cited when a resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully document or plan for the resident's care requirements.
A resident with cognitive impairment and a history of wandering accessed a disinfectant cleaner, leading to chemical burns and acute respiratory failure. The resident was found with the cleaner after a housekeeper had cleaned the room, and staff were unaware of the chemical's presence until symptoms appeared. The facility's failure to secure hazardous materials resulted in the resident's hospitalization.
A facility failed to implement PASRR Level II recommendations for a resident with cerebral palsy, anxiety disorder, and depression, resulting in a delay in therapy services. The resident was not assessed for Occupational and Speech Therapy as agreed upon in a meeting, due to the facility's failure to submit the necessary NFSS form request by the deadline. The Director of Rehab was unaware of the required services until a later meeting, and the facility lacked a PASRR policy, relying on the manual instead.
A resident with a complex medical history, including dementia and an above-the-knee amputation, required extensive assistance for transfers. A CNA attempted to prepare the resident for a transfer using a mechanical lift without the required two-person assistance, leading to the resident nearly falling and sustaining a head injury. Interviews revealed a common practice of preparing residents for transfers alone, despite facility policy requiring two staff members for mechanical lift operations.
The facility failed to ensure sharps containers in six resident rooms and on three medication carts were monitored and changed before becoming overfilled, posing a risk of exposure to bloodborne pathogens. Observations showed containers filled past the Fill Line, and interviews revealed unclear responsibilities among staff. The facility's policy required containers to be discarded when three-quarters full, which was not followed.
The facility failed to provide adequate pharmaceutical services, with discrepancies in narcotic logs and improper documentation by staff. Two medication carts showed mismatches between narcotic administration records and actual pill counts for residents receiving Tramadol, Hydrocodone-Acetaminophen, and Lorazepam. LVNs failed to document administration correctly, leading to potential risks. The DON acknowledged the need for proper documentation and noted a lack of recent in-service training.
The facility failed to secure medications in resident rooms, with four residents having various medications unsecured on their bedside tables. Staff were unaware of these medications, and the facility lacked procedures for self-administration assessments. The oversight posed risks of adverse reactions if other residents accessed the medications.
The facility failed to maintain proper sanitation standards for the ice machine scoop in the kitchen, as observed by the presence of water and gray buildup in the scoop holder. The Dietary Manager, responsible for kitchen sanitization, acknowledged the issue, indicating a lapse in the cleaning routine, which could risk cross-contamination and air-borne illnesses.
A facility failed to maintain an effective infection prevention and control program, as observed during medication administration for two residents with feeding tubes. An LVN did not adhere to proper hand hygiene protocols, using the same gloves after touching various surfaces without changing them or performing hand hygiene before administering medications. Interviews confirmed that the facility's policy required hand hygiene before resident contact, but the LVN acknowledged the failure to follow these protocols.
The facility failed to maintain an effective pest control program, with flies and gnats observed in multiple areas, including the kitchen and hallways. Staff interviews confirmed awareness of the issue, and pest control services were engaged biweekly. Despite these efforts, pests remained present, indicating a deficiency in the program.
A resident with acute respiratory failure was not provided with continuous oxygen therapy as ordered by the physician. Observations showed the resident without the prescribed oxygen during the day, and staff interviews revealed a misunderstanding of the orders, with an LVN believing the oxygen was to be used as needed. The DON confirmed the expectation to follow physician orders but noted a lack of recent training on oxygen therapy.
A resident with multiple health conditions, including cerebral palsy and coronary artery disease, received enteral feeding at an incorrect rate due to a miscommunication during nurse handover. The feeding pump was set at 75 ml/hr instead of the prescribed 70 ml/hr, contrary to the facility's policy requiring verification of physician orders. Staff interviews revealed the error and the expectation for nurses to double-check orders before administration.
Failure to Ensure Resident Access to Call Light System
Penalty
Summary
The facility failed to ensure that two residents had adequate access to the call light system, which is necessary for them to request staff assistance. One resident, a male with end stage renal disease, hemiplegia, aphasia, and moderate cognitive impairment, did not have a call light cord in his room. He reported that he would yell out to staff if he needed something, as he did not have a way to alert them otherwise. Staff members, including a CNA and an LVN, were unaware that this resident lacked a call light cord and noted that he typically called out or went to the nurses' station when he needed assistance. Another resident, a female with encephalopathy, sepsis, urinary tract infection, and impaired functional abilities, was unable to reach her call light cord because it was tied to the bed repositioning bar on the opposite side from where she was seated in her wheelchair. She stated that she would wait for staff to check on her to communicate her needs, as she could not access the call light. A CNA acknowledged that call light cords tied to beds were often out of reach for residents in wheelchairs but had not reported the issue. The ADON and Administrator were not aware of these deficiencies prior to the survey. Facility policy requires that call lights be plugged in and within easy reach of residents at all times.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Nonfunctional Call System in Resident Bathrooms and Bathing Areas
Penalty
Summary
A deficiency was identified due to the lack of a working call system in each resident's bathroom and bathing area. This observation indicates that the required call system, which allows residents to request assistance when needed, was not available or functional in these specific areas of the facility. The absence of a working call system in these locations was directly noted during the survey, leading to the citation.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents’ drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Follow Pureed Diet Recipe Results in Unpalatable and Improperly Textured Meal
Penalty
Summary
A deficiency occurred when a Dietary Aide failed to prepare a pureed lunch meal according to the facility's established recipe, which was designed to conserve nutritive value, flavor, and appearance. During observation, the aide blended breaded chicken fried steak patties with white gravy instead of following the recipe that required beef base and water to create beef broth. The aide acknowledged that she was instructed to use gravy but recognized that the recipe called for broth, and not following it could affect the meal's flavor and acceptability for residents on pureed diets. Further observation and interviews revealed that the pureed chicken fried steak was not smooth and contained grizzled parts, and the spinach lacked flavor. The Dietary Manager confirmed that the recipe was not followed and that the gravy was intended to be added only on top prior to serving. The facility's policy required staff to use and follow provided recipes, but this was not adhered to in the preparation of the pureed meal, resulting in a product that did not meet the required standards for texture and flavor.
Failure to Provide Accessible Call System During Call Light Outage
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with quadriplegia and contractures, who was dependent on staff for all activities of daily living. Following a thunderstorm that caused the facility's call light system to fail, the resident was provided with a temporary call bell that she was physically unable to use due to her contractures and limited arm mobility. The resident reported that her only option to call for help was to yell, which she stated was unreliable. Staff interviews confirmed awareness that the resident could not use the provided bell, and that she normally used a flat push pad call light when the system was operational. Despite staff increasing the frequency of checks on the resident to every 15 to 30 minutes, no alternative communication device that the resident could use was initially provided. The care plan for the resident specifically required that the call light and personal items be kept within reach, and that she be reminded to call for assistance. The facility did not have a policy addressing call lights, and staff acknowledged that the temporary solution did not meet the resident's needs until a modified device was later provided.
Incomplete Discharge Summary Documentation
Penalty
Summary
The facility failed to ensure the completion of a discharge summary for one resident who was reviewed for discharge. Specifically, the discharge summary for a female resident with diagnoses including bipolar disorder, schizophrenia, and depression was not completed following her discharge. The resident's electronic health record lacked a completed Minimum Data Set (MDS) assessment, and the interdisciplinary discharge summary form was missing key sections such as the recapitulation of the resident's stay, physician signature, social services summary, activity summary, and therapy services summary. Nursing notes indicated the resident left the facility against medical advice, with all medications and belongings provided to her at the time of departure. Interviews with facility staff revealed that the social worker had only recently started at the facility and completed only his portion of the discharge summaries for residents. Other departments were responsible for their respective sections, and the medical records staff was tasked with ensuring the entire discharge summary was completed. However, in this case, the medical records staff did not identify the incomplete discharge summary, and the director of nursing confirmed that all departments should have completed their sections. The facility was unable to provide a discharge summary policy prior to the survey exit.
Failure to Coordinate PASRR Assessment After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for one resident who was reviewed for PASRR assessments. The resident, an older female with severe cognitive impairment and a BIMS score of 03, was admitted with active diagnoses of depression disorder and anxiety disorder. On a later date, she received a new diagnosis of schizophrenia, but the facility did not refer her to the appropriate state-designated mental health authority for review, nor was a new PASRR evaluation completed as required. The initial PASRR Level 1 screening did not indicate a mental illness, and the new diagnosis was not followed up with the necessary assessment. Interviews revealed that the DON was aware a new PASRR evaluation should have been completed after the new diagnosis, but the responsible MDS nurse was transitioning to another facility and did not follow up or inform others. The Regional MDS nurse was not aware of the new diagnosis until notified by the DON and confirmed that no new PASRR screening had been done. The facility administrator stated there was no specific PASRR policy in place, and the facility relied on state guidelines.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. This failure to assist affected residents who were dependent on staff for basic daily functions.
Failure to Provide Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including COPD, heart failure, and a history of stroke, was not provided respiratory care in accordance with physician orders. The resident was ordered to receive continuous oxygen at 2 liters per minute via nasal cannula, with staff responsible for monitoring and maintaining this level each shift. However, observations on multiple occasions revealed the resident was receiving oxygen at 3 liters per minute. The resident confirmed she was supposed to be on 2 liters and was unaware of any change to 3 liters. Nursing staff, including an LVN, also confirmed the order was for 2 liters and could not identify who had increased the oxygen flow or when the change occurred. The LVN acknowledged that any change in oxygen delivery should be communicated to and ordered by a physician, and that staff were responsible for monitoring and documenting oxygen levels each shift. The DON stated that staff should check the resident's oxygen level, tubing, and water each shift, and that any changes to oxygen flow should be documented and ordered by a physician. The DON also noted that the resident or family members sometimes changed the oxygen level, necessitating staff education to prevent unauthorized adjustments. Review of facility policy confirmed that licensed nursing staff are required to provide treatments as ordered by the physician. The failure to ensure the resident received oxygen therapy as ordered, and to monitor and document changes, resulted in a deficiency related to the provision of safe and appropriate respiratory care.
Failure to Accurately Document and Account for Narcotic Administration
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate narcotic counts and documentation for two residents receiving pain management medications. Specifically, on one medication cart, the narcotic administration records for morphine sulfate and oxycodone did not match the actual pill counts in the blister packs for two residents. The nurse responsible for administering these medications admitted to giving the medications but failed to sign off on the Narcotic Administration Record log as required by facility policy. This lapse in documentation was confirmed during interviews, where the nurse acknowledged forgetting to sign and recognized the importance of this step. Further interviews with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) revealed that both expected staff to document narcotic administration on both the Medication Administration Record (MAR) and the narcotic log, but neither could recall the last time they audited the medication carts. Additionally, when training records on narcotic administration were requested, none were provided. The facility's own policy required immediate documentation of controlled medication administration, including date, time, amount, and nurse's signature, which was not followed in these instances.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled according to currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions resulted in noncompliance with regulations regarding the proper labeling and secure storage of medications and biologicals within the facility.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved in the deficiency.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Resident Ingests Disinfectant Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, resulting in a serious incident involving a resident with cognitive impairment. The resident, who had a history of wandering and cognitive deficits related to dementia, was found with a bottle of disinfectant cleaner containing ammonium chloride compounds. This occurred after a housekeeper had cleaned the resident's room earlier in the day. The resident was later observed with symptoms consistent with chemical ingestion, including swollen lips and vomiting, and was subsequently sent to the hospital. The resident's medical history included a progressive neurological condition, high blood pressure, diabetes, and Alzheimer's disease. The resident's care plan noted his tendency to wander and his cognitive deficits, which required specific interventions to address unmet needs. Despite these documented needs, the resident was able to access a hazardous chemical, leading to a diagnosis of acid burns to his oral mucosa and acute respiratory failure, necessitating intubation. Interviews with facility staff revealed that the disinfectant spray was found on the resident's bedside table, and there was uncertainty about how the resident obtained it. The staff, including CNAs and LVNs, were not aware of the presence of the chemical until after the incident occurred. The facility's policy required that cleaning supplies be locked away, but it was unclear how the disinfectant ended up in the resident's possession, highlighting a lapse in adherence to safety protocols.
Failure to Implement PASRR Recommendations for Resident
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination and evaluation report for a resident reviewed for PASRR assessments. The resident, a female with cerebral palsy, anxiety disorder, and depression, was admitted to the facility with severe cognitive impairment and speech deficits. Despite a meeting held on January 6th, where it was agreed that the resident would be assessed for Occupational and Speech Therapy, the facility did not submit the necessary NFSS form request by the specific deadline, resulting in a delay in therapy services. The Director of Rehab was not initially involved in the PASRR meeting and was unaware of the required therapy services until a subsequent meeting on February 14th. Following this meeting, the necessary paperwork was completed, and the resident was assessed for occupational therapy on February 16th. The Administrator revealed that the previous MDS Nurse was responsible for PASRR meetings and was unaware of the approval for new services through PASRR. The facility did not have a PASRR policy covering PASRR positive policy and procedures, relying instead on the manual.
Inadequate Supervision and Assistance in Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required extensive assistance with transfers and mobility. A Certified Nursing Assistant (CNA) did not follow the resident's care plan and attempted to prepare the resident for a transfer using a mechanical lift without the required assistance. This action placed the resident at risk, resulting in an incident where the resident nearly fell from the bed and sustained a head injury. The resident involved was an elderly female with a complex medical history, including dementia, psychotic disturbance, Type II diabetes, unsteadiness of feet, lack of coordination, and an above-the-knee amputation of the right leg. Her care plan indicated she was a fall risk and required a two-person assist for bed mobility and transfers. Despite this, the CNA attempted to prepare the resident for a transfer alone, leading to the resident rolling off the bed and hitting her head on the bed rail. Interviews with staff revealed that it was common practice for aides to prepare residents for mechanical transfers alone before calling for help. However, the facility's policy required two staff members for mechanical lift operations. The Director of Nursing (DON) and MDS Coordinator acknowledged the discrepancy between the resident's MDS assessment, which indicated a need for extensive assistance, and the actual practice of allowing one-person assistance. This inconsistency contributed to the incident, as the resident's condition required more support than was provided.
Failure to Monitor and Change Overfilled Sharps Containers
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that sharps containers in six resident rooms and on three medication carts were monitored and changed before becoming overfilled. Observations revealed that sharps containers in Rooms 330, 340, 602, 704, 707, and 710, as well as on medication carts for the 300, 500, and 700 Halls, were filled past the designated Fill Line, preventing the disposal flaps from closing properly. This oversight could potentially expose residents to bloodborne pathogens due to improper disposal of used sharps. Interviews with staff, including LVNs and the ADON, indicated a lack of clarity and responsibility regarding the monitoring and changing of sharps containers. LVN A and LVN B acknowledged the risk of exposure to used sharps due to overfilled containers, while the ADON and DON stated that all nursing staff were responsible for changing the containers. The DON admitted to being unaware of the fill line on the sharps containers and expressed the need for immediate staff education. The facility's Infection Control policy, dated January 2022, specified that sharps containers should be discarded when three-quarters full, a guideline that was not adhered to in this instance.
Inadequate Pharmaceutical Services and Documentation Errors
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by discrepancies in narcotic logs and improper documentation by staff. On two medication carts, the narcotic administration records did not match the actual pill counts for residents receiving Tramadol and Hydrocodone-Acetaminophen. Specifically, the narcotic administration record for one resident showed 17 pills remaining, while the blister pack contained 16 pills. Similarly, another resident's record indicated 50 pills remaining, but the blister pack had 49 pills. These discrepancies were due to the failure of LVN E to document the administration of narcotic medications correctly and in a timely manner. Additionally, LVN G also failed to document the administration of Lorazepam accurately, resulting in a mismatch between the narcotic administration record and the blister pack count. Interviews with the LVNs revealed that they were aware of the requirement to sign off on the narcotic count sheet immediately after administration but failed to do so due to being busy or forgetting. The Director of Nursing (DON) acknowledged the expectation for staff to document narcotic medications when administered and noted that recent in-service training on medication administration had not been conducted.
Failure to Secure Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and labeled according to professional principles, as required by State and Federal laws. This deficiency was observed in four residents who had medications unsecured in their rooms. Resident #102 had a bottle of nystatin powder on her bedside table, which she brought from the hospital without the facility's knowledge. Resident #167 had multiple inhalers and nebulization solutions on his bedside table, which he used daily without proper storage. Resident #170 had a bottle of ibuprofen tablets on her bedside table, which she used as needed for pain. Resident #175 had a bottle of Vitamin C tablets on his bedside table, which was brought by a family member and taken daily. The facility's staff, including LVN D, were unaware of the presence of these medications in the residents' rooms until the survey. LVN D acknowledged that residents should not have medications in their rooms and that it was the nurse's responsibility to check and secure medications. The facility did not have any residents assessed for self-administration of medications, and the staff had been trained on medication storage. However, the training did not prevent the oversight of unsecured medications in residents' rooms. Interviews with the ADON and DON revealed that their expectations were for staff to check residents' rooms for medications and notify doctors and families if found. They emphasized the risk of other residents taking unsecured medications, which could lead to adverse reactions. The facility's Medication Storage policy did not address medications stored at bedside for self-administration, indicating a gap in their procedures.
Ice Machine Scoop Sanitation Deficiency
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety, specifically in relation to the cleanliness of the ice machine scoop in the facility's only kitchen. During an observation, it was noted that the ice machine scoop holder contained about a half inch of water with gray color buildup floating in it. The Dietary Manager, responsible for kitchen sanitization, acknowledged the issue upon discovery and mentioned that staff had been trained to clean the ice machine and scoop holder every two or three days. However, the presence of water and buildup indicated a lapse in maintaining the cleanliness standards, which could potentially lead to cross-contamination and air-borne illnesses among residents.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during medication administration for two residents with feeding tubes. Both residents, who were severely cognitively impaired and required feeding tubes due to dysphagia, were observed during medication passes. LVN A did not adhere to proper hand hygiene protocols, which included washing hands and changing gloves before and after resident contact. Specifically, LVN A was observed using the same gloves after touching various surfaces, such as the medication cart and bed controls, without changing gloves or performing hand hygiene before administering medications through the residents' feeding tubes. Interviews with LVN A and the Director of Nursing (DON) confirmed that the facility's policy required hand hygiene before resident contact and after contact with environmental surfaces. Despite having received in-service training on infection control, LVN A acknowledged the failure to follow these protocols. The DON reiterated the expectation for staff to practice appropriate hand hygiene and confirmed that the facility had conducted in-service training on handwashing and equipment cleaning. However, the observations indicated a lapse in adherence to these infection control practices, potentially placing residents at risk for infection.
Deficiency in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flies and gnats in various areas, including the kitchen, dining room, and hallways. Observations on consecutive days revealed multiple instances of flies and gnats in the kitchen, around the breakfast cart, and near the nurse's station. Interviews with staff, including the Dietary Manager and Maintenance Director, confirmed awareness of the pest issue. The Dietary Manager reported the problem to the Maintenance Director, who stated that pest control services were engaged biweekly and could respond on the same day if needed. Despite these measures, pests were still present, indicating a deficiency in the pest control program. A resident reported having roaches in her shower, which were addressed by the Maintenance Director and subsequently treated by the pest control company. The housekeeper also noted an increase in gnats and would report sightings to the Maintenance Director. The pest control log showed regular treatments targeting various pests, including flies and gnats, but the continued presence of these pests suggests that the program was not fully effective. The Maintenance Director mentioned using commercial-grade products and blue light sticky strips to manage the issue, but no structural damage was identified as a cause for pest entry.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident who required continuous oxygen therapy as per physician orders. The resident, who had been diagnosed with acute respiratory failure, was observed multiple times without the prescribed 2 liters per minute of oxygen via nasal cannula. Despite the physician's order for continuous oxygen every shift, the resident was only using oxygen at night, and the oxygen tubing was found on the top of her bed during the day. The resident was unsure if the oxygen was supposed to be continuous, indicating a lack of communication and understanding of her care plan. Interviews with the facility staff revealed a misunderstanding of the physician's orders. An LVN assigned to the resident believed the oxygen was to be administered as needed, rather than continuously, and acknowledged that failure to follow the orders could lead to adverse health effects such as shortness of breath and hypoxia. The Director of Nursing confirmed that all nurses were expected to adhere to physician orders for oxygen therapy, but noted that no recent in-service training had been conducted on this issue, as it had not been previously identified as a problem.
Incorrect Enteral Feeding Rate Administration
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding. Specifically, the facility did not administer the enteral feed at the correct rate of infusion for a resident. The resident, a male with cerebral palsy, lung disease, anemia, aphasia, coronary artery disease, and gastroesophageal reflux disease, was dependent on staff for all activities of daily living. A physician's order had changed the tube feeding rate from 75 ml/hr to 70 ml/hr, but the feeding pump was observed to be infusing at the incorrect rate of 75 ml/hr. Interviews with staff revealed that the error occurred due to a miscommunication during the nurse handover, where the off-going nurse reported no changes in orders. The Licensed Vocational Nurse (LVN) acknowledged the mistake upon reviewing the order and corrected the feeding rate. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the expectation was for nurses to check and double-check orders before administering tube feedings. The facility's policy required checking the physician's order for formula, route, rate, and frequency, which was not adhered to in this instance.
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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