Town Hall Estates Arlington, Inc.
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 824 W Mayfield Rd, Arlington, Texas 76015
- CMS Provider Number
- 676080
- Inspections on file
- 34
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 37 (3 serious)
Citation history
Health deficiencies cited at Town Hall Estates Arlington, Inc. during CMS and state inspections, most recent first.
A resident with dementia and schizophrenia, assessed as a moderate risk for wandering, was left unsupervised outside after the receptionist left, allowing her to leave the facility grounds unnoticed. Staff did not previously identify her as an elopement risk, and she was found walking down the street before being safely returned by staff. The lapse in supervision led to the deficiency.
A resident did not receive appropriate care for existing pressure ulcers, and measures to prevent new ulcers were not consistently implemented, resulting in a deficiency related to pressure ulcer management.
A resident with moderate cognitive impairment and multiple diagnoses began receiving antipsychotic medications before the responsible party signed consent forms, with no documentation of verbal consent prior to administration. Staff interviews confirmed that consents should be obtained before medication is given, but the process was not followed, and the facility lacked a specific policy on consents.
A resident with multiple chronic conditions and severe cognitive impairment was not assisted in obtaining dentures, despite being edentulous and expressing a desire for them. The Social Services Director did not follow up on a dental referral for over five weeks, contrary to facility policy requiring timely vendor contact. The resident remained without dentures and continued on a mechanical soft diet.
Surveyors found unsanitary conditions in the kitchen, including a long-standing dark substance on the walk-in cooler floor that had not been cleaned, and improper food storage practices such as previously thawed and re-frozen ground beef in an unlabeled, undated bag. The Dietary Manager acknowledged both issues and confirmed that proper cleaning and food storage procedures were not followed.
Staff did not consistently use required PPE when providing care to a resident on enhanced barrier precautions for wounds and a urinary catheter. Despite signage and available PPE, several staff members transferred the resident without wearing gowns and gloves, citing unfamiliarity with the residents or not noticing the signage. Interviews revealed gaps in staff understanding of EBP and infection control protocols, and there was no monitoring in place to ensure PPE compliance.
A resident with severe cognitive impairment and multiple diagnoses had a privacy curtain with a dried brown substance that remained unreported and uncleaned for several days. Staff interviews revealed that all staff were responsible for reporting soiled curtains to maintenance for cleaning, but this process was not followed, resulting in the curtain remaining dirty despite facility policy requiring immediate laundering or replacement.
A resident receiving enteral nutrition via a gastrostomy tube was found to have their feeding pump set at a higher rate than ordered by the physician. Nursing staff and facility policy required verification of the correct rate, but this was not done, resulting in the resident receiving nutrition at an incorrect rate until the error was identified and reported.
A resident with severe cognitive impairment received wound care from an RN who failed to change gloves and perform hand hygiene between the dirty and clean phases of the procedure. Despite the facility's infection control policy and staff training, this lapse was observed, highlighting a deficiency in maintaining a safe and sanitary environment.
The facility failed to implement comprehensive care plans for three residents, affecting their ability to receive necessary care. A resident with moderate cognitive impairment lacked a care plan for her Apixaban medication. Another resident with severe cognitive impairment did not have a care plan for his Foley catheter, and a third resident with neurological conditions lacked a care plan for her medications. The interdisciplinary team, including the MDS Coordinator and DON, did not update the care plans, impacting care continuity.
A facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy due to the absence of physician orders and inadequate maintenance of oxygen equipment. The resident, with chronic obstructive pulmonary disease, did not have an active order for oxygen use, and the nasal cannula and humidifier were not changed weekly as required. Staff were unaware of these deficiencies, and the facility lacked a policy on oxygen treatment, placing the resident at risk for respiratory issues.
The facility failed to ensure accurate documentation and administration of narcotic medications for two residents, leading to discrepancies in narcotic counts on two medication carts. Nurses admitted to not logging narcotics immediately after administration, citing being busy as the reason. Interviews revealed that the facility's policy required end-of-shift narcotic counts, which were not consistently followed.
The facility failed to properly label and store medications, resulting in expired drugs on a medication cart and unsecured eye drops at a resident's bedside. Nursing staff did not consistently check for expired medications, and a resident's previous order to keep eye drops at the bedside was not renewed, posing risks of overmedication and access by others.
The facility failed to maintain sanitary practices in the kitchen due to the dishwashing machine not performing at the optimal sanitation rate. The absence of chlorine and the use of expired and incorrect test strips were observed. Dietary staff, including the Dietary Manager, were unaware of the correct ppm required and the importance of using non-expired test strips. As a result, lunch was served using disposables. The facility's policy and the U.S. Public Health Service Food Code were not adhered to, posing potential health risks for residents.
The facility failed to obtain necessary physician orders for two residents, impacting their care. One resident lacked orders for flushing a gastrostomy tube between medications, while another had no specified catheter size in their orders. The LVN and ADON acknowledged these omissions, which could lead to improper care. The facility's policy requires immediate recording of verbal orders, which was not followed.
The facility failed to ensure accurate advance directives for two residents, leading to inconsistencies in their code status records. One resident had a care plan indicating full code status without an active physician order, while another had a DNR status without an order. Staff interviews revealed gaps in maintaining accurate records, with the DON acknowledging that orders might have been missed during readmissions.
A medication error occurred when an LVN failed to flush a resident's gastrostomy tube between medications, resulting in an 8.57% error rate. The resident's orders only specified flushing before and after medication administration, not between, leading to potential risks of tube blockage and medication interactions. Interviews revealed that the facility's policy required flushing between medications, but the orders were incomplete.
A resident with severe cognitive impairment and multiple medical conditions, including a pressure ulcer, did not receive proper incontinence care. Staff used multiple briefs, contrary to protocol, to manage heavy urination and prevent urine from reaching a pressure wound. This practice, acknowledged by staff to potentially cause skin breakdown, was not addressed by facility leadership despite awareness of the issue.
The facility failed to report a resident-to-resident altercation involving a serious injury within the required 2-hour timeframe. One resident with severe cognitive impairment was attacked by another resident with dementia, resulting in a head laceration that required staples. The incident was not reported to the State Survey Agency until the next day, violating federal regulations.
A treatment cart containing medications and supplies was left unattended and unlocked in a hallway, allowing unauthorized access. The assigned LVN was unaware the cart was unsecured while assisting with incontinent care. The facility's policy requires carts to be locked when not in use.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and prevent an accident involving a resident with dementia and schizophrenia. The resident, who had a moderate cognitive impairment as indicated by a BIMS score of 8, was allowed to sit outside the front of the building unsupervised after the receptionist left for the day. Despite being assessed as a moderate risk for wandering, the resident was not identified as an elopement risk prior to the incident and was not provided with the necessary supervision to prevent her from leaving the facility premises. On the day of the incident, the resident was last seen approximately 15 minutes before being found walking down the street with her walker, away from the facility. She was observed by a former staff member, who notified facility staff. The resident was subsequently approached and escorted back to the facility by staff without injury. Interviews with staff and the responsible party revealed that the resident had not previously attempted to leave the facility, but she was known to enjoy sitting outside and sometimes expressed confusion or a desire to wait for family members. The facility's staff, including CNAs, LVNs, and administrative personnel, reported that they were aware of policies regarding elopement and wandering, but the resident was not considered an elopement risk before this event. The receptionist, who typically monitored the resident while she was outside, had left and asked the resident to come inside, but the resident remained unsupervised. This lapse in supervision allowed the resident to leave the facility grounds unnoticed, resulting in the deficiency.
Failure to Provide Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in the standard of care required to address and mitigate pressure ulcer risks.
Failure to Obtain Informed Consent Prior to Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided consent prior to the administration of antipsychotic medications. Record review showed that the resident, who had moderate cognitive impairment and diagnoses including depression and Alzheimer's Disease, began receiving Olanzapine and Aripiprazole as ordered by the physician. However, the consent forms for these medications were not signed by the responsible party until several weeks after the medications had already been administered. There was no documentation of verbal consent being obtained prior to the administration of the first doses. Interviews with facility staff revealed that the ADONs were responsible for obtaining consents before administering antipsychotic medications, and that the process sometimes involved obtaining verbal consent over the phone, which should be documented with the date. The responsible party for the resident did not recall giving consent or discussing the medications over the phone. Additionally, the facility administrator was unable to provide a policy regarding consents for antipsychotic medications at the time of the survey.
Failure to Assist Resident in Obtaining Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining routine dental care, specifically in scheduling an appointment for dentures, despite being aware of the resident's edentulous status and her expressed desire for dentures. The resident, an elderly female with chronic kidney disease, non-Alzheimer's dementia, diabetes mellitus, and schizophrenia, was admitted without upper or lower teeth and required a mechanical soft diet. Her care plan identified dental problems and included interventions such as daily oral care and referral to social services for dental follow-up. Documentation showed that the social worker attempted to initiate a dental referral by leaving a voicemail but did not follow up further for at least five weeks. During interviews, the resident reported being bothered by the lack of teeth and expressed a strong desire for dentures. The Social Services Director acknowledged responsibility for scheduling dental appointments and admitted not having contacted the referred dental company or determined the necessary documentation, citing lack of time. The Administrator confirmed that follow-up on dental referrals was the Social Services Director's responsibility, with ultimate accountability falling to the Administrator if not completed. Facility policy required contact with outside vendors within three business days of referral initiation, which was not met in this case.
Failure to Maintain Sanitary Food Storage and Handling Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically in the walk-in cooler where a dark substance measuring approximately 12 inches by 4 inches was found on the non-porous floor. The Dietary Manager acknowledged that the substance had built up over the years and had not been cleaned, stating that nothing had been attempted to remove it. The Dietary Manager also indicated that it was his responsibility to ensure the kitchen was clean and sanitary, but believed the substance did not affect residents' health since it was not in direct contact with food. Additionally, the facility failed to properly store and discard food items in the freezer. A clear, unlabeled, and undated sealed plastic bag containing previously defrosted and re-frozen ground beef was found, with a puddle of frozen blood inside. The Dietary Manager confirmed that the ground beef should not have been re-frozen and that this practice could put residents at risk of foodborne illness. The meat had been placed in the freezer by a new cook who was unaware of proper procedures, and the Dietary Manager had not noticed the item prior to the survey. Review of the facility's policy confirmed that thawed products should not be refrozen and that refrigeration units should be kept clean.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to use appropriate personal protective equipment (PPE) when providing care to a resident who was on enhanced barrier precautions (EBP) due to wounds and a urinary catheter. Observations showed that on multiple occasions, staff members transferred the resident between bed and wheelchair without wearing the required gown and gloves, despite clear signage indicating the need for PPE and the presence of PPE supplies nearby. Interviews revealed that some staff were unfamiliar with the residents on EBP, did not notice the signage, or did not understand the meaning of EBP, leading to lapses in infection control practices. The resident involved was an elderly female with a history of leg fracture with surgical repair, dementia, and kidney failure, requiring assistance with activities of daily living and placed on isolation precautions for a surgical wound. The facility had several residents on isolation for various reasons, and signage was used to indicate EBP status. Staff interviews indicated inconsistent knowledge and adherence to PPE protocols, and the Director of Nursing confirmed that while in-services on infection control were provided, there was no monitoring to ensure staff compliance with PPE use.
Failure to Maintain Clean Privacy Curtain in Resident Room
Penalty
Summary
A deficiency was identified when a resident's privacy curtain was observed to have a dried brown substance measuring approximately 0.5 cm x 1 cm. Multiple staff interviews confirmed that it was the responsibility of all staff to report soiled privacy curtains to the maintenance department, which would then remove, launder, and rehang the curtains. Despite this policy, the soiled curtain was not reported to the maintenance director, and the curtain remained dirty over multiple days of observation. Staff members, including CNAs, LVNs, and housekeeping, acknowledged the importance of keeping privacy curtains clean for infection control and resident dignity, but the required reporting and cleaning process was not followed in this instance. The resident involved was an elderly female with severe cognitive impairment, non-Alzheimer's dementia, anxiety, and stage 2 chronic kidney disease. She required supervision for activities of daily living and reported that the dirty curtain did not affect her daily life, partly due to poor vision. Review of facility policy confirmed that privacy curtains should be laundered or replaced immediately if soiled, but this procedure was not adhered to, resulting in a failure to maintain a sanitary and comfortable environment for the resident.
Failure to Follow Physician Orders for Enteral Feeding Rate
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube was provided care in accordance with physician orders. The resident, who had a history of nontraumatic intracerebral hemorrhage, diabetes mellitus, and dysphagia following a stroke, was observed with her feeding pump set at 60 ml/hr, despite a physician order specifying a rate of 50 ml/hr. The care plan and physician orders detailed the required formula, feeding rate, and water flushes, but these were not followed as observed during the survey. Interviews with nursing staff and review of facility policy confirmed that the enteral feeding pump rate should match the physician's order, and that it is the responsibility of nursing staff to verify and set the correct rate. The incorrect rate was identified by a nurse during rounds, who acknowledged the error and reported it to the ADON. Both the ADON and DON stated their expectations that nurses follow physician orders and verify pump settings during rounds, as outlined in facility policy. The failure to follow the physician's order for the enteral feeding rate constituted the deficiency.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of RN A during wound care for a resident. The resident, who was admitted with a traumatic subdural hemorrhage and had severe cognitive impairment, required substantial assistance with daily activities. During an observation, RN A did not change gloves or perform hand hygiene after removing the old dressing and cleaning the wound, before applying a new dressing. This lapse in protocol was acknowledged by RN A, who admitted to not washing hands between the dirty and clean phases of wound care. Interviews with other staff members, including an LVN, a CNA, the ADON, and the DON, revealed a general understanding of the importance of hand hygiene and glove changes during wound care. They all reported having received training on infection control and handwashing. The DON, who also serves as the facility's Infection Preventionist, emphasized the necessity of washing hands before, after, and in-between care, and acknowledged the risk of cross-contamination if these practices are not followed. The facility's handwashing policy, revised in August 2015, mandates the use of hand hygiene procedures to prevent the spread of infections. It specifies that hand hygiene should be performed before handling clean or soiled dressings and before moving from a contaminated to a clean body site. Despite this policy and the training provided, the failure to adhere to these procedures during the observed wound care session resulted in a deficiency in the facility's infection control program.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for three residents, which could affect their ability to receive necessary care and services. Resident #27, a female with moderate cognitive impairment and multiple diagnoses including hyperlipidemia, did not have a care plan addressing her Apixaban medication, prescribed to prevent blood clots and strokes. This oversight was noted in her records, which lacked documentation of the medication order in her care plan. Resident #39, a male with severe cognitive impairment and an indwelling catheter, did not have a care plan addressing his Foley catheter. His physician's orders specified a monthly catheter change, but the care plan did not reflect this requirement, nor did it specify the catheter size. During an observation, Resident #39 was found in a hospital emergency unit without a Foley catheter, highlighting the lack of proper documentation and care planning. Resident #52, a female with progressive neurological conditions and multiple medications, did not have a care plan addressing her current medication orders, including Mirtazapine, Donepezil, and Seroquel. The facility's interdisciplinary team, including the MDS Coordinator and DON, were responsible for updating care plans, but the necessary updates were not made, potentially affecting the continuity of care for these residents.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as evidenced by the absence of physician orders for the resident's oxygen use. The resident, an elderly female with intact cognition, had multiple active diagnoses including chronic obstructive pulmonary disease, which necessitated the use of oxygen. Despite this, there was no active physician's order for oxygen therapy, and the resident's care plan indicated the need for oxygen as ordered. This oversight was confirmed through record reviews and interviews with staff, who acknowledged the lack of an order and the responsibility of the admitting nurse to ensure all necessary orders were entered. Additionally, the facility did not adhere to professional standards regarding the maintenance of the resident's oxygen equipment. Observations revealed that the resident's nasal cannula and humidifier were not changed weekly as required, with the nasal cannula appearing discolored and undated. Interviews with the resident and staff confirmed that the nasal cannula had not been replaced for several weeks, and the humidifier bottle's date was illegible. Staff members, including an LVN and the ADON, admitted to being unaware of the lack of equipment maintenance and the absence of a physician order, which could lead to infection or inadequate oxygen delivery. The facility's failure to provide a policy on oxygen/respiratory treatment and to follow physician orders further compounded the issue. The DON was not aware of the missing orders and emphasized the importance of obtaining physician orders to ensure proper care. The lack of a policy and the failure to follow established procedures for changing the nasal cannula and humidifier bottle weekly were significant factors contributing to the deficiency, placing the resident at risk for respiratory concerns.
Inaccurate Narcotic Documentation and Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in the accurate documentation and administration of narcotic medications for two residents. On two medication carts, the narcotic logs for two residents were found to be inaccurate. For one resident, the narcotic administration record showed a discrepancy between the logged and actual count of Acetaminophen with Codeine tablets. The nurse involved admitted to not logging the administration of the medication, attributing the oversight to being busy. Another resident's narcotic administration record for Tramadol also showed a discrepancy between the logged and actual count of pills. The nurse responsible for this resident's medication admitted to forgetting to sign off on the narcotic administration log after administering the medication. Both nurses acknowledged the importance of logging narcotics immediately after administration to prevent drug diversion and discrepancies. Interviews with the ADON and DON revealed that the facility's policy required nurses to count controlled medications at the end of each shift, with both the incoming and outgoing nurses participating in the count. However, it was found that the nurses did not consistently follow this policy, leading to discrepancies in narcotic counts. The facility had conducted in-services on medication administration and narcotic logging, but the staff failed to adhere to these procedures consistently.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, leading to deficiencies in medication management. Specifically, the medication cart for Hall C contained expired medications, including Naloxone tablets, Sodium chloride ophthalmic solution, Aspirin, Zinc sulfate capsules, Debrox ear drops, and Lispro insulin. Interviews with the LVN, ADON, and DON revealed that it was the responsibility of the nursing staff to check and remove expired medications each shift, but this was not consistently done. The expired medications posed a risk of reduced effectiveness. Additionally, a resident was found to have a bottle of eye drops stored unsecured at their bedside, contrary to facility policy requiring medications to be stored in locked compartments. The resident had previously been allowed to keep eye drops at the bedside, but this order was not renewed upon their return from the hospital. The ADON acknowledged the oversight and the risk it posed, including potential overmedication and access by other residents. The nursing staff, including the LVN, were unaware of the unsecured medication, indicating a lapse in monitoring and adherence to storage protocols. The facility's policy on discontinued medications emphasized the timely removal of such medications from the cart and maintaining storage areas in a clean and safe manner. However, the observations and interviews highlighted a failure to adhere to these policies, resulting in expired medications remaining in the cart and unsecured medications at a resident's bedside. This lack of compliance with established procedures contributed to the deficiencies identified during the survey.
Improper Sanitation Practices in Kitchen
Penalty
Summary
The facility failed to maintain sanitary practices in the kitchen, specifically with the dishwashing machine, which was not performing at the optimal sanitation rate due to the absence of chlorine and the use of expired and incorrect test strips. Observations revealed that the dishwashing machine required 50 ppm chlorine, but the test strips used by Dietary Aides E and F were expired and the wrong type, with a first increment of 100 ppm. The chlorine container was found empty, and the staff had to contact maintenance to replace it, as they were unable to lift the heavy container themselves. Dietary Aide F, who had been working at the facility for about six months, admitted to not checking the expiration date of the test strips and was unaware of the correct ppm required for the dish machine. The Dietary Manager, who was responsible for ensuring the facility had the correct type of test strips, also did not know the correct ppm or that the test strips had expiration dates. The Dietary Manager attempted to locate another package of test strips, but they were also expired and incorrect. As a result, lunch was served using disposables because the correct test strips could not be located in time. Interviews with various staff members, including Dietary Aide E and the Cook, revealed a lack of proper training and awareness regarding the importance of using the correct and non-expired test strips. The Dietary Manager acknowledged that the dish machine log was probably inaccurate due to the use of expired and incorrect test strips. The Administrator confirmed that the proper test strips should be used and that the Dietary Manager was responsible for ensuring this was done. The facility's policy and the U.S. Public Health Service Food Code were not adhered to, leading to a risk of improper sanitation and potential health risks for residents.
Failure to Obtain Physician Orders for Medical Procedures
Penalty
Summary
The facility failed to obtain necessary physician orders for two residents, which could potentially impact their care. For one resident, there were no physician orders for flushing the gastrostomy tube with water between medication administrations. The resident, who had severe cognitive impairment and a feeding tube, was only receiving flushes before and after medication administration, as per the existing orders. The Licensed Vocational Nurse (LVN) acknowledged the absence of orders for flushing between medications and admitted to not performing the flushes due to the lack of orders. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were aware of the issue, with the ADON confirming the missing orders and updating them after being notified. Another resident, also with severe cognitive impairment, had an indwelling urinary catheter but lacked specific physician orders for the catheter size. The resident's care plan did not address the Foley catheter, and the physician's orders did not specify the size, leading the LVN to use a French size 18 catheter without consulting the physician. The LVN assumed the omission of the size was intentional and did not verify it, which could lead to inappropriate catheter use. The ADON and DON both recognized the oversight and the potential risks associated with not having a specified catheter size. The facility's policy on medication and treatment orders requires verbal orders to be recorded immediately, including the prescriber's details and the time of the order. However, this protocol was not followed in these cases, leading to the deficiencies noted. The physician involved stated that standard orders for gastrostomy tube flushing should be documented for any resident receiving medications through such a tube, and he expected the staff to update the orders accordingly.
Failure to Ensure Accurate Advance Directives
Penalty
Summary
The facility failed to ensure the residents' rights to formulate an advance directive for two residents, leading to inconsistencies in their code status records. Resident #2, an elderly female with intact cognition and multiple health conditions, had a care plan indicating a full code status. However, her physician order summary report did not have an active order to support this status. Similarly, Resident #27, also with intact cognition and various health issues, had a care plan indicating a Do Not Resuscitate (DNR) status, but her physician order summary report lacked an active order for this status. Interviews with facility staff revealed gaps in the process of maintaining accurate advance directive records. The Social Worker, who joined after the residents' readmissions, acknowledged the risk of not having advance directives in place. LVN G was unaware of the missing advance directive order in the electronic health record for Resident #2 and relied on paper documentation. The ADON admitted to not being aware of the missing orders and emphasized the importance of having orders in place to honor residents' wishes. The DON stated that advance directive orders should be established at admission and reviewed by the ADON and herself. She acknowledged that the orders might have been missed during the residents' last readmissions. The facility's policy requires providing residents with information about their rights to accept or refuse treatment and to formulate advance directives, but the lack of active orders for the two residents compromised the ability to honor their end-of-life wishes.
Medication Administration Error Due to Incomplete Flushing Procedure
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8.57% error rate due to the actions of LVN A. This error involved Resident #57, who had a gastrostomy tube and required specific flushing procedures during medication administration. LVN A did not flush the gastrostomy tube with water between medications, as there were no specific orders for this step, despite being aware of the standard practice. The resident's physician orders only included flushing the tube with 60 ml of water before and after medication administration, not between each medication. The deficiency was observed when LVN A administered medications to Resident #57 without flushing the gastrostomy tube between each medication, which could lead to tube blockage and medication interactions. Interviews with LVN A, the DON, and the ADON revealed that the facility's policy required flushing between medications, but the orders were missing this instruction. The DON and ADON acknowledged the oversight and the importance of following physician orders and facility policy to prevent such errors.
Improper Incontinence Care for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to provide proper incontinence care for a resident who was unable to perform activities of daily living independently. The resident, a male with severe cognitive impairment and multiple medical conditions including a urinary tract infection, pressure ulcer, and neuromuscular dysfunction of the bladder, required total dependence on staff for daily living activities. Despite the care plan indicating the need for incontinence care every two hours and as needed, the staff used multiple incontinence briefs on the resident, which was not in accordance with facility protocol. This practice was intended to prevent urine from traveling to the resident's sacral pressure wound but was acknowledged by staff to potentially cause skin breakdown and irritation. Interviews with various staff members, including an LVN, CNA, ADON, and DON, revealed awareness of the use of double briefs for the resident. The CNA initiated the use of two briefs to manage the resident's heavy urination and prevent urine from reaching the pressure wound. The ADON and DON were aware of this practice but did not instruct staff to discontinue it, despite recognizing the risks of skin breakdown and infection. The facility did not provide a specific policy on pericare or briefing procedures, which contributed to the deficiency in care.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegations were made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. This deficiency was observed in the case of two residents involved in a physical altercation. The incident occurred between a resident with severe cognitive impairment and another resident with moderate cognitive impairment and behavioral issues. The altercation resulted in a serious injury to one of the residents, who sustained a laceration on her head that required staples. Despite the severity of the injury, the incident was not reported to the State Survey Agency within the required 2-hour timeframe. The incident took place when one resident, who was nonverbal and watching TV at the nurse's station, was attacked by another resident wielding a wooden back scratcher. The attacking resident, who had a history of dementia and psychosis, struck the nonverbal resident on the head, causing significant bleeding. The staff immediately intervened, called 911, and provided first aid. The injured resident was transported to the hospital for treatment and returned to the facility later that night. Despite the immediate response to the physical injury, the facility did not report the incident to the appropriate authorities within the mandated 2-hour window. The Director of Nursing (DON) and the Interim Administrator discussed the incident and decided to report it the next day, believing the injury was not serious enough to warrant immediate reporting. The DON did not consider the laceration to be a serious bodily injury and did not classify the incident as abuse due to the attacking resident's dementia. This misjudgment led to a delay in reporting the incident, which is a violation of the facility's policy and federal regulations. The facility's policy clearly states that any alleged violation involving abuse or resulting in serious bodily injury must be reported within 2 hours, a requirement that was not met in this case.
Unsecured Treatment Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents. Specifically, Treatment cart #1 was left unattended and unlocked in the facility's C-hall. The cart contained medications, treatment supplies, and treatment scissors. During the observation, three staff members and four residents passed by the unsecured cart. LVN A, who was assigned to the cart, was unaware that it was left unlocked while she was assisting with incontinent care in a resident's room. LVN A acknowledged that she was trained to lock the cart when not in use and recognized the potential risk of residents accessing the medications if the cart was left unsecured. The Director of Nursing (DON) and the Administrator were informed about the incident. Both confirmed that it was the facility's policy and expectation for nursing staff to secure all medication and treatment carts when not in use. The facility's policy on the security of medication carts, revised in April 2007, mandates that carts must be locked to prevent unauthorized entry. The policy also specifies that carts should be parked in the doorway of the resident's room or against the hallway wall with doors and drawers facing the wall, and must be locked before the nurse enters the resident's room. The failure to adhere to this policy was identified as a deficiency 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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
