Trinity Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Rock, Texas.
- Location
- 1000 E Main St, Round Rock, Texas 78664
- CMS Provider Number
- 675546
- Inspections on file
- 37
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Trinity Care Center during CMS and state inspections, most recent first.
A CNA accessed a resident's personal cell phone and used the resident's mobile cash app to transfer money to herself. The resident, who was cognitively intact and required minimal assistance, noticed the unauthorized transactions and reported the theft. The incident was confirmed through app records and reported to facility staff and law enforcement.
A deficiency was cited for not ensuring a resident's rights to dignity, self-determination, and communication were honored, with no further details provided about the specific circumstances or events.
The facility did not adequately accommodate the needs and preferences of a resident, resulting in a deficiency related to resident-centered care.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of facility practices.
Two residents were found without access to a working call system to request assistance, one due to a missing call light for over a week and another due to a broken and unplugged call light. Both residents had significant medical needs, and staff were unaware of the deficiencies until the time of the survey. Care plans did not address the absence of call lights, and there was no established policy or procedure to ensure timely maintenance or alternative communication methods.
Surveyors identified multiple deficiencies in food storage, labeling, and dating, as well as improper sealing and disposal of expired items. The kitchen ice machine was found with visible slime and mold, and the dry food pantry floor was dirty. Cold foods, including vanilla pudding and fruit cups, were held above safe temperatures and served to two residents, though not consumed. Staff interviews revealed inconsistent adherence to food safety policies and unclear cleaning responsibilities.
A resident with a new diagnosis of unspecified convulsions did not have this condition reflected in their care plan, despite documentation in the medical record and a recent hospital stay for seizures. The care plan lacked seizure-related problems, goals, or interventions, and staff interviews confirmed the omission, which was not in accordance with facility policy.
Surveyors found that the facility did not maintain a sanitary and accessible emergency eyewash station in the kitchen. The eyewash station was dirty, improperly covered, and blocked by clutter such as trash cans, cleaning tools, and meal carts. Staff were unaware of the station's existence or use, and there was no documented training or clear policy regarding its maintenance or accessibility.
A facility failed to update a resident's care plan to reflect a new vegetarian diet order, despite the resident's severe cognitive impairment and health conditions. The LVN responsible for the update did not amend the care plan due to other duties, although the MDS coordinator and ADM confirmed the necessity of timely updates to meet residents' needs.
A resident with severe cognitive impairment and dietary restrictions was served meat despite having a physician's order for a vegetarian diet. The facility's process for verifying meal trays was not followed due to staff being occupied with other duties, leading to the oversight. The resident's responsible party filed grievances, and the facility acknowledged the error.
A resident with severe cognitive impairment fell and sustained serious injuries after a CNA failed to report observed dizziness and left the resident unattended in the shower room. The resident, who required assistance with showering, was categorized as low risk for falls but had a care plan indicating a risk due to confusion and safety unawareness. The facility's staff were instructed not to turn their backs on residents during showers, but the CNA did not follow this protocol, leading to the resident's fall and subsequent death.
A CNA in an LTC facility failed to report a resident's dizziness and did not prepare shower supplies, leading to the resident's fall and serious injuries, including a brain bleed. The resident, who had severe cognitive impairment, was hospitalized and later placed on hospice care, eventually passing away. The facility lacked specific training and protocols for CNAs on reporting changes in condition, contributing to the incident.
The facility failed to report alleged violations and injuries within required timeframes. A resident's fall resulting in a brain bleed and broken bone was not reported to the SA within two hours, and another resident's injury of unknown source was also not reported timely. Interviews revealed a lack of awareness of reporting guidelines among staff.
The facility failed to treat six residents with respect and dignity by not serving their lunch trays at the same time as their tablemates, leading to feelings of neglect and upset among the affected residents. The issue was exacerbated by ongoing construction in the main dining hall, causing delays in meal service and a lack of adherence to the facility's policy of serving all residents at a table simultaneously.
The facility failed to ensure that residents who were unable to conduct ADLs received necessary services to maintain good grooming and personal hygiene. Four residents with various medical conditions were found with jagged fingernails and blackish/brownish substances underneath them, despite being assessed to require assistance with personal hygiene. Staff interviews revealed inconsistencies in the responsibility for nail care.
A resident with multiple health conditions was denied the right to attend a group therapy activity by a CNA, despite her care plan indicating she enjoyed such activities. The CNA incorrectly informed the resident that she could not participate because she was on hospice care, causing the resident visible agitation. Other staff confirmed that hospice residents were allowed to join group therapy activities, and the facility's policy emphasized supporting resident self-determination.
A resident with multiple diagnoses requiring extensive assistance was improperly transferred by a CNA who did not use a gait belt, causing the resident pain. Despite protocols and training in place, the CNA used her hands to pull the resident by her arms, which was not a proper transfer technique. The incident was confirmed by multiple staff members, and the CNA was subsequently blocked from working at the facility.
The facility failed to ensure a resident's hospice care order was signed and dated by the physician, leading to a deficiency in care documentation. The resident, with multiple diagnoses including multiple sclerosis and dementia, was at risk of receiving unconfirmed hospice services due to this oversight.
The facility had a medication error rate of 7%, involving two residents. One resident received a Lidocaine patch on the lower back instead of the left hip as ordered, and another resident did not receive Linaclotide for constipation due to the medication being out of stock.
Misappropriation of Resident Funds by CNA
Penalty
Summary
A certified nursing assistant (CNA) accessed a resident's personal cell phone and used the resident's mobile cash application to transfer two separate amounts of money to herself. The incident was discovered when the resident, who was cognitively intact and required minimal assistance, noticed the unauthorized transactions and reported the theft to another CNA. The resident expressed distress over the incident, and the transactions were confirmed through photos of the cash application on the resident's phone. Interviews and record reviews revealed that the CNA had been employed at the facility following a clear background check, positive references, and a current license. Staff members, including the CNA who received the report and the social worker, confirmed that they had received annual training on abuse, neglect, exploitation, and misappropriation of funds. The facility's policy required immediate reporting of such incidents to the administrator, state agencies, ombudsman, resident representatives, and law enforcement. Despite these policies and training, the CNA was able to access the resident's property and misappropriate funds. The incident was reported to the administrator and social worker, who began gathering evidence and notified the police. The resident was later discharged from the facility for unrelated insurance reasons.
Failure to Honor Resident Rights to Dignity and Self-Determination
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these fundamental rights were upheld for the resident, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or observations related to the resident's experience.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of each resident. This deficiency was identified during the survey process, indicating that the facility did not take adequate steps to ensure that residents' individual needs and preferences were met as required.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Working Call Systems for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had access to a working communication system to call for assistance, as required for reasonable accommodation of resident needs. One resident, who had a history of nontraumatic intracerebral hemorrhage, acute respiratory failure with hypoxia, expressive dysphasia, and hemiplegia, did not have a call light or bell in her room from the time of admission. Observations and interviews confirmed that the resident's room lacked a call light for over a week, and neither the care plan nor staff actions addressed this absence. The Director of Nursing (DON) and other staff were unaware of the missing call light until the day of the survey, and there was no policy or procedure in place for call lights or maintenance requests. Maintenance staff had not received a request for a call light until the survey date, despite staff stating that a request had been made earlier. A second resident, with diagnoses including cerebral infarction, diabetes, arthritis, and dementia, was also found without a functioning call light. The call light cord was observed unplugged and broken, and the resident was unable to use it to request assistance. Staff were unaware of how long the call light had been nonfunctional, and the resident's care plan specifically required the call light to be within reach and for staff to respond promptly to requests for assistance. Interviews with staff and the DON revealed a lack of awareness regarding the status of the call lights and the absence of a systematic process to ensure their functionality. These deficiencies were identified through direct observation, interviews with staff, residents, and family members, and review of care plans and facility policies. The lack of a working call system in both cases was not addressed in the residents' care plans, and staff did not consistently monitor or ensure the availability of alternative communication methods when the call lights were not functional.
Deficiencies in Food Storage, Sanitation, and Temperature Control
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. Surveyors observed multiple instances where food items in the reach-in refrigerator, walk-in refrigerator, and walk-in freezer were not labeled or dated, including trays of fresh cut fruit, bags of fried okra, and containers of unidentified substances. Some food items were not properly sealed, exposing them to air and potential contamination. Expired food items were found in storage, and staff were unsure of the correct timeframes for discarding refrigerated foods. Staff interviews confirmed inconsistent adherence to labeling, dating, and sealing policies, despite training and established facility procedures. The facility also failed to maintain proper sanitation of kitchen equipment and areas. The ice machine in the kitchen was found with a black/brown slime and an unidentified substance inside the chute, with water dripping onto the ice. The prefilter was visibly dirty, and the machine had not been cleaned in over a year, contrary to manufacturer recommendations and facility policy. The dry food pantry floor was observed to be dirty, with dust, food particles, stains, and residue present. The hand-washing sink near the dishwasher was cluttered and inaccessible due to cleaning equipment and supplies blocking access. Staff interviews revealed confusion about cleaning responsibilities and a lack of regular checks on the cleanliness of the ice machine and pantry area. Additionally, the facility did not ensure that cold foods were held at safe temperatures. Vanilla pudding and fruit cups were found to be above the required 41 degrees Fahrenheit, with pudding measured at over 66 degrees Fahrenheit. Despite staff awareness of temperature requirements, these foods were served to two residents at lunch, though the residents did not consume them. Staff and management acknowledged the importance of proper food storage and temperature control, but failed to consistently implement these practices, as evidenced by observations and interviews.
Failure to Update Care Plan for New Seizure Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had recently received a new diagnosis of unspecified convulsions (seizures). Although the resident's face sheet and MDS assessment reflected the new diagnosis, the care plan did not include seizures as a problem, nor did it outline goals or interventions related to seizure management. The resident, who had a severely impaired cognitive status as indicated by a BIMS score of 03, had experienced witnessed seizures and a subsequent hospital stay before returning to the facility. Despite these events, the care plan was not updated to address the new diagnosis. Interviews with facility staff, including the MDS Nurse, DON, ADM, and BOM, confirmed that the policy required care plans to be updated when new diagnoses were identified. However, the staff acknowledged that the care plan had not been revised to reflect the resident's seizure disorder. The facility's policy emphasized the importance of updating care plans to ensure all staff are informed and able to provide appropriate care, but this was not followed in this instance.
Failure to Maintain Sanitary and Accessible Emergency Eyewash Station in Kitchen
Penalty
Summary
The facility failed to maintain a safe, sanitary, and accessible emergency eyewash station in the kitchen. During multiple observations, the eyewash station was found with a roll of paper towels inside the basin, a visible white film or residue, and the protective eyewash covers were not properly positioned or capped. The area around the station was cluttered and blocked by various items including a trash can, brooms, a dustpan, a meal tray cart with soiled trays, a box of gloves, and rolls of trash bags, making the station inaccessible. Signage was present instructing staff to keep the area clear and to test the equipment weekly, but these instructions were not followed. Interviews with dietary staff revealed a lack of awareness about the existence and use of the emergency eyewash station, and no documented training was provided to staff regarding its use. The Dietary Manager (DM) stated that staff were responsible for cleaning their own areas and that the Maintenance Director was responsible for servicing the eyewash station, but there was no clear policy or documented training on the eyewash station. The inspection task sheet for the eyewash station included instructions for keeping the area clear and the covers in place, but these were not adhered to, and the DM was unsure how often inspections were performed. The Administrator confirmed there was no policy for the eyewash station and acknowledged the area was cluttered, which did not meet expectations for cleanliness and accessibility.
Failure to Update Care Plan for Dietary Change
Penalty
Summary
The facility failed to develop and implement a complete care plan that met the current needs of a resident, specifically regarding dietary interventions. The resident, an elderly female with severe cognitive impairment and multiple health conditions including malnutrition and dementia, had a physician's order for a vegetarian diet. However, the care plan did not reflect this dietary change, as it lacked a goal or intervention for a vegetarian diet. This oversight was identified during a review of the resident's care plan and physician orders. Interviews with facility staff revealed that the responsibility for updating the care plan fell to LVN F, who acknowledged receiving a request to update the resident's diet to vegetarian but failed to do so due to being occupied with other duties. The MDS coordinator confirmed that care plans should be updated when orders change, and the ADM emphasized the importance of timely updates to ensure residents' needs are met. The facility's policy on comprehensive person-centered care plans also supports the need for ongoing assessments and revisions as residents' conditions change.
Failure to Accommodate Resident's Vegetarian Diet
Penalty
Summary
The facility failed to provide food that accommodates a resident's dietary preferences, specifically a vegetarian diet, for one of the residents reviewed. The resident, an elderly female with severe cognitive impairment and multiple health issues, including malnutrition and dementia, was admitted to the facility with a physician's order for a vegetarian diet with puree texture and nectar thick consistency. Despite this, the resident received meat on her meal tray on multiple occasions, as noted in grievances filed by her responsible party (RP). The deficiency occurred due to a breakdown in the facility's process for ensuring residents receive the correct meals. The Director of Nursing (DON) stated that the facility's process involved dietary staff reviewing special instructions on meal tickets, charge nurses verifying the meal tickets, and CNAs delivering the trays. However, on the day in question, the charge nurses were occupied with other duties and did not verify the meal tray, leading to the resident receiving meat. The kitchen staff acknowledged the error, and the kitchen manager confirmed that the meal ticket had instructions for no meat, but the tray was not checked before delivery. Interviews with staff revealed that the oversight was due to multiple staff members being busy with other tasks, resulting in the failure to verify the meal tray. The resident's RP became upset upon discovering the error, leading to a confrontation with the facility staff. The facility's policy on tray service emphasizes the importance of accurate tray service and meeting residents' preferences, but the lack of a formal verification policy contributed to the deficiency.
Neglect Leads to Resident's Injury and Death
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a serious injury and subsequent death. A certified nursing assistant (CNA) observed signs of dizziness in a resident but did not report this change in condition to a nurse. Instead, the CNA proceeded to take the resident to the shower room. While the CNA's back was turned, the resident attempted to stand up unassisted, fell, and sustained a nondisplaced right inferior pubic ramus fracture and a right parietal scalp hematoma with an underlying acute traumatic subarachnoid hemorrhage. The resident was sent to the emergency room and later placed on hospice care, where she passed away. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 3. She required partial/moderate assistance with showering and supervision or touching assistance with tub-shower transfers. Her care plan noted she was at risk for falls due to confusion, incontinence, and being unaware of safety needs. Despite these risks, the facility's fall risk evaluation categorized her as low risk for falls, and she had no recorded falls since admission until the incident. Interviews with facility staff revealed that CNAs were responsible for showering residents and were instructed never to turn their backs on residents during showers. However, the CNA involved did not adhere to this protocol and failed to report the resident's dizziness to a nurse, citing the absence of a nurse on duty at the time. The facility's Director of Nursing (DON) and other staff members confirmed that CNAs were expected to report any changes in a resident's condition immediately. The facility lacked documented evidence of training related to falls, abuse, neglect, and change in condition for the CNA involved.
Inadequate CNA Competency Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a certified nursing assistant (CNA A) had the necessary competencies to provide safe care, resulting in a serious incident involving a resident. CNA A did not report signs of dizziness observed in a resident before taking her to the shower room. The resident, who had severe cognitive impairment and required assistance with showering, fell in the shower room after CNA A turned her back to grab supplies. This fall resulted in the resident sustaining a nondisplaced right inferior pubic ramus fracture, a right parietal scalp hematoma, and an acute traumatic subarachnoid hemorrhage. The resident was admitted to the hospital following the fall, where her condition deteriorated, leading to her being placed on hospice care. The resident eventually passed away due to the brain bleed caused by the fall. Interviews with other CNAs and licensed vocational nurses (LVNs) revealed that it was standard practice to never turn their back on a resident in the shower room and to have all shower supplies prepared beforehand. However, CNA A did not follow these protocols and failed to notify a nurse of the resident's change in condition, which was a critical oversight. The facility's documentation and interviews indicated a lack of specific training and protocols for CNAs regarding the notification of changes in a resident's condition. The facility's policies did not clearly outline the responsibilities of CNAs in such situations, contributing to the incident. Additionally, there was no evidence of recent training for CNA A related to falls, abuse, neglect, and change in condition, highlighting a gap in the facility's training and competency evaluation processes.
Failure to Timely Report Alleged Violations and Injuries
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, within the required timeframes. Specifically, the facility did not report Resident #1's fall, which resulted in a brain bleed and broken pubic bone, to the State Agency (SA) within the mandated two-hour window. The incident occurred when Resident #1 fell in the shower, and although the family was informed, the facility delayed notifying the SA until after the family reported the brain bleed discovered at the hospital. Similarly, the facility did not report Resident #2's injury of unknown source within the required timeframe. Resident #2 was found with a hematoma on the forehead, a skin tear, and a swollen wrist, which was later confirmed as fractured. The incident was unwitnessed, and the resident was sent to the hospital for evaluation. Despite the severity of the injuries, the facility failed to notify the SA within the two-hour requirement for injuries of unknown origin. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed a lack of awareness and adherence to the reporting guidelines. The DON admitted to not knowing the exact time of the observations and reports made by the staff, and the ADM was unaware that injuries of unknown origin required reporting within two hours. This lack of timely reporting could potentially affect the health and safety of the residents, as it delays the necessary investigations and interventions.
Failure to Serve Meals Simultaneously
Penalty
Summary
The facility failed to treat six residents with respect and dignity by not serving their lunch trays at the same time as their tablemates. This resulted in some residents having to wait for their meals while others at the same table were already eating. For instance, Resident #1 had to wait approximately 35 minutes after her tablemates received their food, which made her feel bad and neglected. Similarly, Resident #2 had to wait until his tablemate finished eating before receiving his lunch tray, and Resident #3 was observed trying to grab food from another resident's plate due to the delay in receiving her meal. The issue was exacerbated by ongoing construction in the main dining hall, which led to the use of an auxiliary dining hall with limited space. The food carts were delivered to Unit C at different times, causing delays in meal service. Staff interviews revealed that the food carts were not brought to the unit simultaneously, and the trays were not served according to the seating chart. This led to some residents feeling neglected and upset, as they had to wait for their food while others were eating. The facility's policy stated that all residents at one table should be served at the same time to ensure a dignified dining experience. However, this policy was not followed, leading to a lack of respect and dignity for the affected residents. Staff members, including CNAs, LVNs, and the Dietary Manager, acknowledged the issue and stated that the current system was problematic. The DON and Administrator also recognized the dignity problem and emphasized the importance of serving all residents at a table simultaneously to prevent feelings of neglect and ensure a positive dining experience for all residents.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the fingernails of four residents were trimmed and cleaned. This deficiency was observed in residents with various medical conditions, including hemiplegia, hemiparesis, muscle weakness, type 2 diabetes mellitus, contractures, autistic disorder, seizures, chronic pain, and cognitive impairments. The residents were assessed to require extensive or total assistance with personal hygiene, yet their fingernails were found to be jagged and had blackish/brownish substances underneath them during observations and interviews conducted by surveyors. Resident #4, a male with hemiplegia and hemiparesis, was observed with jagged fingernails and blackish/brownish substances underneath them. Despite being assessed to require extensive assistance with personal hygiene, his nails were not properly maintained. Similarly, Resident #52, who had contractures and seizures, was found with jagged fingernails and blackish/brownish substances underneath them. This resident was assessed to require total dependence on one staff member for personal hygiene. Resident #73, who had type 2 diabetes mellitus and chronic pain, was also observed with jagged fingernails and blackish/brownish substances underneath them. This resident was assessed to be totally dependent on one staff member for personal hygiene. Lastly, Resident #109, who had muscle weakness and type 2 diabetes mellitus, was found with jagged fingernails and blackish/brownish substances underneath them. This resident required limited assistance with personal hygiene. Interviews with staff revealed inconsistencies in the responsibility for nail care, with some staff believing it was the responsibility of CNAs and others believing it was the responsibility of nurses, particularly for diabetic residents. The facility's policy on ADLs indicated that residents would be provided with care to maintain good grooming and personal hygiene, but this was not adhered to in these cases.
Failure to Support Resident Self-Determination
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for one resident reviewed for self-determination. The resident, who had multiple diagnoses including multiple sclerosis, anxiety disorder, type 2 diabetes, dysthymic disorder, major depressive disorder, unspecified dementia, and cauda equina syndrome, was denied the right to attend a group therapy activity by a CNA. The resident expressed a desire to attend the group therapy exercise but was told by the CNA that she could not because she was on hospice care, which caused the resident visible agitation and mental anguish. The resident's care plan indicated that she was very social, loved to be out in activities settings, and attended all special events. The care plan also specified that CNAs were to assist and escort the resident to activity functions. Despite this, the CNA did not facilitate the resident's participation in the group therapy activity. Other staff members, including another CNA and a Physical Therapy Assistant (PTA), confirmed that there was no policy preventing hospice residents from attending group therapy activities. The PTA later verified with the Director of Rehabilitation (DOR) that hospice residents were indeed allowed to join group therapy activities. Interviews with the Director of Nursing (DON) and the Administrator revealed that staff were expected to allow residents to attend therapy activities regardless of their hospice status. The DON acknowledged that the CNA should have inquired about the resident's eligibility to join the activity before denying her request. The Administrator also stated that CNAs should not be deciding which activities residents could attend and recognized that being denied participation could make the resident feel sad and upset. The facility's policy on Resident Rights emphasized the importance of treating all residents with kindness, respect, and dignity, and supporting their right to self-determination.
Improper Transfer Technique Leading to Resident Pain
Penalty
Summary
The facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents, specifically in the case of a resident who was improperly transferred from her bed to a wheelchair. The resident, who had multiple diagnoses including osteoarthritis, osteoporosis, muscle weakness, and difficulty walking, required extensive assistance with transfers. Despite this, a CNA did not use a gait belt during the transfer, causing the resident pain in her right arm between the elbow and wrist. The CNA admitted to not using the gait belt, which was a requirement for such transfers, and acknowledged the mistake during an interview. The resident's medical records indicated she required extensive assistance with one staff person for transfers and had a history of pain management. Observations and interviews revealed that the CNA used her hands to pull the resident by her arms, which was not a proper transfer technique. The resident expressed pain during and after the transfer, although no visible injuries such as redness or bruising were observed. Multiple staff members, including the Director of Nurses and other CNAs, confirmed that the use of a gait belt was mandatory for such transfers and that the improper technique used could potentially cause injuries. Interviews with various staff members, including the Director of Nurses, LVNs, and the Administrator, confirmed that the facility had protocols and training in place for proper transfer techniques, including the use of gait belts. However, the CNA involved did not follow these protocols, leading to the incident. The facility's policy on safe lifting and movement of residents emphasized the use of appropriate techniques and devices to ensure the safety and well-being of both staff and residents. The CNA was subsequently blocked from working at the facility by the agency that employed her.
Failure to Obtain Signed Hospice Order for Resident
Penalty
Summary
The facility failed to ensure that Resident #1's physician signed and dated the verbal order for hospice care. This deficiency was identified during a review of Resident #1's records, which revealed that the hospice care order was not signed by the attending physician. The resident, a female with multiple diagnoses including multiple sclerosis, anxiety disorder, type 2 diabetes, and dementia, was readmitted to the facility and required hospice services. However, the necessary documentation to confirm these services was missing from her chart, placing her at risk of receiving unconfirmed hospice care. During interviews, the Director of Nursing (DON) and the Registered Nurse Coordinator (RNC) acknowledged the absence of the signed hospice order in Resident #1's chart. The DON stated that the hospice order was eventually found and placed in the resident's chart, but it was initially missing. The RNC explained that the facility's policy required an order for hospice services to be in place, but the admitting nurse did not follow through with this requirement. The RNC also mentioned that the facility's electronic chart indicated the resident was on hospice, which may have led staff to assume the order was already in place. The facility's policy on medication orders and early identification of end-of-life procedures was reviewed, revealing that a current list of orders must be maintained in each resident's clinical record. Despite this policy, the facility failed to ensure that Resident #1's hospice order was signed and dated by the physician, leading to a deficiency in the resident's care documentation. Interviews with staff indicated a lack of clarity and adherence to the policy, contributing to the oversight in obtaining the necessary hospice order for Resident #1.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not five percent or greater, resulting in a medication error rate of 7%. This was based on two errors out of 32 opportunities, involving two residents. For Resident #15, the medication aide applied a Lidocaine 4% patch to the resident's lower back instead of the left hip as ordered. Despite the resident experiencing pain in the lower back, the order was not updated to reflect this change. The medication aide admitted to applying the patch to the lower back based on past practice rather than the current physician's order. This discrepancy was confirmed through interviews with the medication aide and a licensed vocational nurse, who emphasized the importance of following the physician's orders precisely and updating them as needed. For Resident #274, the facility failed to administer Linaclotide 290 mcg PO for constipation as ordered. The medication was not given on four consecutive days because it was out of stock, and the facility did not obtain approval to administer it due to its high cost. The medication aide and a registered nurse confirmed that the medication was not available and that an alternative treatment was sought. The facility's policy on medication administration, which includes verifying the right drug, dose, route, time, and documentation, was not followed in these instances, leading to the observed deficiencies.
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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