Villa Toscana At Cypress Woods
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 15015 Cypress Woods Medical Dr, Houston, Texas 77014
- CMS Provider Number
- 676239
- Inspections on file
- 33
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Villa Toscana At Cypress Woods during CMS and state inspections, most recent first.
Multiple cognitively impaired and medically complex residents were not consistently offered adequate fluids or provided with accessible water at the bedside, despite care plans identifying potential fluid deficits and a facility policy requiring regular hydration offerings. Observations on multiple days found residents in bed or in wheelchairs without water or other fluids within reach, with some receiving only small 4–8 oz portions of juice or milk on meal trays and no additional water. Staff described confusion over who was responsible for filling ice chests, reported that fresh water was not passed on certain halls for two days, and noted that meal trays did not routinely include water. The LD and MD stated residents should be offered at least 1500–1900 cc of fluids daily, while documented meal offerings were below this amount, and the DON and ADON acknowledged that expected hydration rounds and ice water service each shift were not carried out as observed.
A resident with severe cognitive impairment, multiple complex medical conditions, and contracted hands was care planned to use the call light for assistance and fall prevention, with staff directed to keep it within reach and encourage its use. Despite this, the resident was repeatedly observed yelling for help from his room while a standard call button, difficult for him to operate due to his hand contractures, was within reach. The resident reported that using the standard call button required extreme effort, and CNAs reported he could not effectively use it and requested a flat call button to accommodate his needs, but subsequent observations showed he still had only the standard device. This resulted in a failure to reasonably accommodate the resident’s needs for an accessible call system as required by the facility’s resident rights policy.
A resident with severe cognitive impairment, bowel and bladder incontinence, and dependence on staff for toileting hygiene was not checked or provided incontinence care for approximately six hours during the day, despite a care plan directing checks every two hours and frequent incontinence care. Observations showed the resident in common areas for much of the day in the same clothing, and the resident reported her brief had not been changed since getting out of bed. Electronic surveillance indicated no return to the room for care during this period, and incontinence care was documented only in the early morning and late evening. Staff interviews and facility policy confirmed that residents should be checked and changed every two to three hours, but this did not occur for this resident.
A nurse left a computer screen displaying a resident's confidential health information open and unattended on a locked nursing cart, making the information visible to unauthorized individuals. The resident involved had multiple medical conditions and moderate cognitive impairment. Staff acknowledged responsibility for securing information and confirmed receipt of HIPAA training, but the incident revealed a lapse in following established privacy protocols.
Three residents were found with bed rails in use without physician orders or documented assessments for medical necessity. Staff interviews revealed inconsistent understanding of restraint policies, with some staff unaware that bed rails could be considered restraints or that a doctor's order was required. Facility policy required assessment and informed consent prior to bed rail use, but these procedures were not followed, and multiple residents had bed rails in use without proper evaluation.
Two residents with severe cognitive impairment were found to have untrimmed, thick, and abnormally curved toenails, with one resident experiencing pain and difficulty wearing shoes. Despite care plans and facility policy requiring regular nail care, staff interviews revealed confusion about responsibility and a lack of follow-through, resulting in untreated abnormal nail conditions.
A resident did not receive ordered medications after an RN signed for a pharmacy delivery without verifying its contents, and the medications could not be located when needed. Interviews with LVNs and the DON revealed inconsistent practices in medication cart audits and verification of received medications, with loose pills found in medication carts and staff admitting to not always checking deliveries. Facility policy required proper storage and verification, but these procedures were not followed, resulting in the deficiency.
During a medication cart audit, two unidentifiable loose pills were found at the bottom of a drawer, with staff interviews revealing inconsistent practices in medication cart audits and verification of received medications. The DON acknowledged training on medication storage but was unclear on specific policies regarding loose pills, and the facility's policy requires immediate removal of such medications. This resulted in a failure to ensure all drugs and biologicals were stored and labeled according to professional standards.
The facility's medication error rate was 18.52%, exceeding the acceptable threshold of 5%. Errors included unavailability and incorrect administration of medications for three residents. Staff interviews revealed lapses in ensuring medication availability and correct administration, contributing to the high error rate.
The facility failed to label Latanoprost eye drops with expiration dates for five residents, as observed during a review of medication carts. Staff interviews revealed a lack of adherence to the facility's medication storage policy, which requires dating medications when opened. This oversight could lead to residents receiving expired medications, potentially affecting their therapeutic effectiveness.
The facility failed to properly label and date leftover food items in the walk-in cooler and stored expired food products in the pantry, risking food-borne illnesses. The Dietary Manager acknowledged the oversight, and the Corporate Dietitian confirmed the interchangeable use of 'used by' and 'best by' dates in company policy.
A resident with Alzheimer's and severe cognitive impairment was admitted to a facility but did not receive her prescribed medications on the day of admission. Despite having systems to obtain medications from an emergency kit or automated dispensing system, the medications were not administered, and staff could not explain the oversight. The facility's policy required medications to be administered at the first scheduled time after arrival, which was not followed.
Multiple residents with cognitive and physical impairments were subjected to abuse by another resident with a history of behavioral issues, despite a care plan requiring 1:1 supervision. The resident in question slapped two other residents on the same day, and staff interviews and documentation revealed confusion and lapses in the implementation of required supervision, resulting in residents being placed at risk of harm.
A medication aide was observed eating on the med cart, failing to sanitize hands, equipment, and the cart before and during medication administration for three residents with complex medical needs. The aide did not follow hand hygiene protocols, did not sanitize the blood pressure cuff between uses, and handled medications and equipment after touching potentially contaminated surfaces, contrary to facility policy.
A resident with hemiplegia and hemiparesis was found without a call light within reach, leading to a delay in care as she was left saturated with urine. The facility's call light system was not functioning, and staff failed to ensure the manual bell was accessible, despite being trained to conduct 15-minute checks. This oversight placed the resident at risk of not receiving timely assistance.
A resident in an LTC facility did not receive timely incontinent care due to staff inaction and a non-functioning call light system. The resident, who required assistance with ADLs, was found soaked in urine, expressing discomfort and frustration. Staff interviews revealed a lack of adherence to the protocol of checking on residents every 15 minutes, contributing to the delay in care.
A resident with multiple medical conditions, including cognitive deficits and osteoporosis, fell from bed and fractured her femur due to inadequate supervision. A CNA mistakenly believed the resident required only one-person assistance, contrary to the care plan that specified two-person assistance for bed mobility. This oversight led to the resident rolling off the bed during incontinence care, resulting in a serious injury.
A resident with dementia and other health issues developed a rash, but the LTC facility failed to notify the physician promptly. Despite ongoing itching and scratching, the rash was not communicated to the physician or family, as indicated in weekly skin assessments. The facility's policy required immediate notification of significant changes, but this was not followed, delaying medical intervention.
A resident with dementia and other health issues developed an unexplained rash due to the facility's failure to conduct timely skin assessments. Despite a history of skin problems, the resident's condition was not documented or communicated to the physician, leading to a delay in care. Staff interviews revealed a lack of awareness and communication regarding the resident's condition, and the facility lacked a clear protocol for reporting changes in skin condition.
Two residents with dementia eloped from a memory care unit due to inadequate supervision and unsecured doors. The facility failed to ensure proper monitoring and response to door alarms, allowing the residents to exit the unit. Staff interviews revealed inconsistencies in monitoring procedures and security measures, contributing to the elopements.
Failure to Consistently Offer and Maintain Accessible Hydration for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that multiple residents were consistently offered sufficient fluids and had fluids within reach, as required by their care plans and the facility’s hydration policy. Eight residents with severe cognitive impairment and various medical conditions, including renal disease, dementia, Parkinson’s disease, cerebrovascular disease, malnutrition, and mobility deficits, were observed on multiple occasions without accessible drinking water or other fluids at their bedsides or in their rooms. Care plans for these residents identified potential fluid deficits related to conditions such as dialysis, poor memory, low intake, memory loss, dementia, and ADL self-performance deficits, and included interventions such as encouraging fluids, ensuring fluids were within reach, and informing nursing staff if residents refused fluids. Meal tickets for these residents showed they were typically provided between 24 and 32 ounces of fluids per day on meal trays, often in small 4–8 ounce portions of juice or milk, with no additional water routinely present on the trays. On specific observation dates, surveyors repeatedly found residents in bed or in wheelchairs with no water or other fluids within reach, despite their dependence on staff for transfers and assistance with eating and drinking. One resident with end stage renal disease and dysphagia had a 32‑ounce cup of water placed on a windowsill out of reach and reported the water was not fresh and that he did not know when it had last been refilled; at another meal he drank the only 8‑ounce drink on his tray and stated he would drink more if more were available. Other residents were observed waiting for breakfast or asleep in bed with no water at the bedside, and in some cases the only fluids present during meals were small cups of juice and milk. Several residents were unable to independently access fluids placed on shelves or other surfaces out of reach, and some expressed thirst or a desire for water when asked. Staff interviews and environmental observations further described systemic issues with the hydration process. An ice chest on one hall was observed with only an inch of water and a few ice cubes early in the morning, and later the same day it still contained only an inch of water with the ice melted or removed. A CNA reported uncertainty about who was responsible for filling the ice chest, stated that on two days no one filled it and fresh water was not passed on certain halls, and noted that residents who could not get up had to ask for water. The CNA also stated that the cups on meal trays were small and that trays did not routinely include water. The licensed dietitian stated that residents should be offered about 64 ounces of fluid daily, with a minimum of 50 ounces even for those with fluid restrictions, and acknowledged that if residents received only small amounts at meals, nursing would need to consistently offer additional fluids. The ADON and DON both stated that fresh ice water was expected to be passed every shift and that ice chests and scoops were to be maintained, but acknowledged that for at least two days nursing staff had not ensured residents received fresh ice water and that meal trays did not include water. The facility’s hydration policy required staff to offer hydration during direct care interactions, around meals, during medication passes, and during activities, and to maintain fresh water at the bedside when not contraindicated, but observations and interviews showed these practices were not consistently followed for the residents reviewed. Additional interviews with nursing staff and administration confirmed that there was no clearly assigned responsibility for filling and cleaning the ice chests each shift, and that the ice machine on one side of the building was broken, requiring staff to go to the other side for ice. A CNA reported that aides were supposed to fill pitchers with water every two hours when the ice chest was filled, but that they waited for someone to fill the chest and, during the two days in question, this did not occur. The ADON and DON both stated that residents were also receiving fluids through medication administration and beverages such as juice, milk, and coffee at and between meals, but acknowledged that ice water needed to be offered every shift and that the observations made during the survey were not consistent with their expectations. The medical director and licensed dietitian both indicated that residents should be offered at least 1500–1900 cc (50–64 ounces) of fluids daily, while the documented meal offerings for the affected residents fell below this minimum, and the lack of consistent bedside water and hydration rounds contributed to residents not being offered the minimum quantity of fluids on the days observed.
Failure to Provide Accessible Call Light for Resident With Contracted Hands
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences regarding use of the call light system. The resident was an older male with multiple diagnoses including end stage renal disease, altered mental status, bipolar disorder, metabolic encephalopathy, thrombocytopenia, congestive heart failure, restlessness and agitation, dysphagia, muscle weakness, abnormal posture, and cognitive communication deficit. His admission MDS showed a BIMS score of 06, indicating severe cognitive impairment, and documented no limitations in upper extremity range of motion. His care plan identified an ADL self-care performance deficit and risk for falls, with interventions directing staff to ensure the call light was within reach and to encourage him to use it for assistance. On multiple observations, the resident was heard repeatedly yelling “Nurse! Nurse!” from his room instead of using the call button. During one observation, the ADON responded after the second episode of yelling and found the resident with a standard call button within reach. Both of his hands were contracted. In a subsequent interview and observation, the resident stated he knew how to press the call button but had great difficulty doing so because of his hands. He demonstrated that he could pick up the call button with his right hand and use a finger on his left hand to press it, but this required extreme effort and concentration. Additional observations showed the resident continuing to yell for assistance, with staff responding to his calls from the hallway. Staff interviews confirmed that the resident was unable to effectively use the standard call button due to his contracted hands. A CNA who regularly worked on the resident’s hall stated that he could not use the call button and that she and another aide had notified the nurse on the hall that he needed a flat call button to accommodate his condition. Another observation documented a CNA asking an LVN to obtain a flat call button so the resident could more easily use it and stop yelling into the hall. However, a later observation showed that the resident still had the standard call button and no flat button, and he stated he would have liked and used a flat call button if he had one he could more easily press. The facility’s Resident Rights policy stated that residents have the right to reside and receive services with reasonable accommodation of their needs and preferences, which was not implemented for this resident’s call light needs.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living, specifically toileting hygiene and incontinence care, to a cognitively impaired resident who was fully dependent on staff for these needs. The resident was an elderly female with diagnoses including cerebral infarction, cognitive communication deficit, lack of coordination, overactive bladder, and dementia, and her quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment. Her care plan documented bowel and bladder incontinence, with goals to prevent complications and maintain function, and interventions that included checking her every two hours, assisting with toileting as needed, and providing frequent incontinence care with moisture barrier application. On the date in question, documentation of toileting hygiene and incontinence care tasks reflected that the resident received incontinence care at 12:17 AM and again at 8:56 PM, with no care recorded for the day shift between 6 AM and 2 PM. Observations showed the resident seated in the living room eating breakfast at 9:15 AM and later participating in activities and receiving lunch, remaining in the same clothing throughout the morning and early afternoon. During an interview in the late morning, the resident stated that her brief had not been changed since she got out of bed, though she could not specify the time. Review of automated electronic surveillance video for that day showed that the resident’s room camera did not activate between 9:10 AM and 3:30 PM, with activation only when she was brought back to her room and provided incontinence care at 3:30 PM. The family member reported monitoring the video and stated they did not see the resident return to her room for incontinence care until that time, and that they had to call the nurse’s station to request care. Facility staff, including an RN, a CNA, the DON, and the ADM, all stated that residents should be checked and changed every two to three hours, and the facility’s perineal care policy required incontinent residents to be checked and changed as needed based on an appropriate schedule. Despite these expectations and policies, the resident was not checked or provided incontinence care for approximately six hours during the day.
Failure to Secure Resident Health Information on Unattended Computer Screen
Penalty
Summary
A deficiency occurred when a nurse left a computer screen displaying a resident's personal health information open and unattended on a locked nursing cart in a hallway. The computer was left visible for several minutes, during which time anyone passing by, including visitors or other residents, could have seen the confidential information. The nurse acknowledged receiving HIPAA training and stated she was responsible for closing the computer screen when stepping away. The Director of Nursing confirmed that facility policy requires screens to be minimized when not in use and that monitoring is conducted through observation rounds. The resident whose information was exposed was a 55-year-old male with multiple medical conditions, including intestinal obstruction, colon cancer, ileostomy status, essential hypertension, and mild intellectual disabilities, with a BIMS score indicating moderate cognitive impairment. Facility records confirmed that staff receive HIPAA training at hire and annually, and that policies require locking or logging off devices when unattended. However, documentation showed that in-service training on cart protocol was only recently provided, with no earlier records available for review.
Failure to Assess and Document Medical Need for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, specifically bed rails, without proper evaluation for medical necessity. Three residents were observed with both side bed rails raised on their beds, yet none had physician orders or documented assessments justifying the use of bed rails. Interviews with residents and their representatives revealed that the bed rails were not requested by the residents and were instead implemented by staff, often as a measure to prevent falls. One resident was observed attempting to get out of bed while the bed rails were up, indicating a lack of individualized assessment for their use. Staff interviews demonstrated inconsistent understanding and application of restraint policies. Some staff members believed that bed rails did not require a physician's order and did not consider them restraints, while others stated that an order and assessment were necessary. The Director of Nursing acknowledged that the facility aimed to be restraint-free but admitted that bed rails were used for mobility assistance and to prevent falls, despite some incidents of bruises and skin tears associated with their use. There was no evidence that residents had been properly assessed for the risks and benefits of bed rail use, nor that informed consent had been obtained prior to installation. Facility policy required assessment for risk of entrapment, review of risks and benefits, and informed consent before bed rails were used, but these steps were not documented or followed for the residents in question. Observations confirmed that bed rails were in use for multiple residents during the survey, and staff interviews further highlighted a lack of training and awareness regarding restraint policies and the potential for bed rails to be considered restraints.
Failure to Provide Regular Toenail Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate foot care for two residents, resulting in untrimmed, thick, and abnormally curved toenails. Observations revealed that both residents had toenails approximately one inch long, yellowish, thick, and in some cases, digging into the skin. One resident reported pain and an inability to wear shoes due to the condition of her toenails. Both residents were noted to have severe cognitive impairment and required assistance with personal care, including dressing and footwear. Record reviews indicated that both residents had care plans identifying self-care deficits and interventions for nail care, such as checking and trimming nails during bathing. However, interviews with staff, including CNAs, the DON, and the social worker, revealed a lack of clarity and follow-through regarding responsibility for toenail care. Staff stated that a podiatrist visited the facility every 62 to 90 days and that non-diabetic residents should receive toenail care from facility staff during showers. Despite these policies, staff were unaware of why the residents' toenails had not been trimmed or referred to the podiatrist. The facility's ADL Nail Care Policy required regular and safe nail management to promote cleanliness and prevent infection or injury. Despite this policy, both residents were observed with abnormal nail conditions, and staff interviews confirmed that expected nail care was not provided. The lack of toenail care was not explained by staff, and the residents remained with untreated, overgrown toenails at the time of the survey.
Failure to Verify and Account for Delivered Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident by not ensuring that medications delivered from the pharmacy were properly checked and accounted for before being signed off by nursing staff. Specifically, an RN signed for a medication delivery without verifying the contents of the package, and the medication could not be located when needed. The Director of Nursing (DON) confirmed that the nurse did not confirm what was in the bag and could not recall who opened the package. The hospice nurse later requested the medication, but it was missing, and the facility was unable to determine its whereabouts. Interviews with several LVNs revealed inconsistent practices regarding the verification and auditing of medication carts (MCs) and the handling of loose medications. LVNs reported that audits of the MCs should be done daily, but loose medications were found at the bottom of the carts, which could indicate that residents did not receive their medications as prescribed. One LVN admitted to never verifying medications sent from the pharmacy, and another described the process for handling controlled medications but did not mention verification of non-controlled medications. The DON and ADM both acknowledged that staff are responsible for verifying and signing off on medications upon receipt, and that failure to do so could result in residents not receiving their medications. Record review showed that the RN who signed for the medication delivery documented receiving specific medications and storing them in the narcotic lock box, but the medications were not found when needed. The facility's policy required medications to be stored safely and securely, with outdated or compromised medications removed immediately. Despite these policies, the lack of proper verification and storage led to the deficiency, as medications were not properly tracked or accounted for, resulting in the potential for residents to miss doses.
Loose, Unidentifiable Medications Found in Medication Cart
Penalty
Summary
A deficiency was identified when an audit and observation of medication cart #1 revealed two unidentifiable loose pills at the bottom of a drawer, under blister packs. Multiple interviews with LVNs confirmed that daily audits of medication carts are expected, but loose medications can occur when pills are accidentally dropped during administration. Staff acknowledged that such occurrences could result in medications not being administered as prescribed. One LVN described the loose pills as potentially an antipsychotic and melatonin. Another LVN stated that she had never verified medications received from the pharmacy, and described the process for handling controlled and reordered medications, indicating inconsistencies in medication management practices. The Director of Nursing (DON) confirmed that training on medication storage had been provided, but could not recall the last time she received it and was unsure of the specific policy regarding loose medications in carts. The DON and other staff stated that both the ADON and the pharmacist are responsible for monitoring medication carts through regular checks. The facility's policy requires that medications be stored safely, securely, and properly, and that any outdated, contaminated, or unidentifiable medications be immediately removed. Despite these policies, the presence of loose, unidentifiable pills in the medication cart indicated a failure to adhere to proper medication storage and labeling protocols.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an observed error rate of 18.52%. This was based on 5 errors out of 27 opportunities, involving three residents. The errors included the unavailability and incorrect administration of medications. Specifically, Resident #26 did not receive Ferrous Sulfate and Calcium-Vitamin D as ordered, and Resident #37 did not receive Glucosamine HCL 500 mg as prescribed. Additionally, Resident #77 was administered the wrong dosage of Fish Oil and an incorrect formulation of a B-Complex vitamin. The observations revealed that the medications for Residents #26 and #37 were not available on the medication cart at the time of administration. Medication Aide G was unable to find the correct dosages and notified the nurse, but the medications were held instead of being administered. For Resident #77, the wrong dosage of Fish Oil and an incorrect B-Complex vitamin were administered, as confirmed by Medication Aide H during an interview. Interviews with staff, including the Director of Nursing (DON) and Assistant Directors of Nursing (ADONs), highlighted that the facility's process for ensuring medication availability and correct administration was not followed. The DON and ADONs acknowledged that they typically check medication orders to ensure they match the facility's stock and contact doctors for updates if needed. However, the failure to have the correct medications available and administered as ordered led to the observed medication errors.
Failure to Label Latanoprost Eye Drops with Expiration Dates
Penalty
Summary
The facility failed to ensure that all drugs and biologicals used in the facility were labeled with expiration dates when applicable, specifically for Latanoprost eye drops used by five residents. During observations, it was noted that the Latanoprost eye drops for Residents #20, #81, #35, #2, and #299 were not labeled with an open or expiration date. This oversight was identified during a review of the medication carts in the facility, where it was found that the eye drops were either not labeled with an open date or were being stored at room temperature without proper labeling. Interviews with facility staff, including medication aides and nursing staff, revealed a lack of adherence to the facility's policy on medication storage. Staff members acknowledged that eye drops should be dated when opened to ensure they are not used past their expiration date. The Director of Nursing (DON) and other nursing staff admitted to not knowing the policy by memory and recognized the potential for reduced effectiveness of medications if expired eye drops were administered to residents. The facility's policy on medication storage, which was reviewed, clearly states that medications requiring an open date should be labeled accordingly. The specific instructions for Latanoprost eye drops indicate that they should be refrigerated until initial use and expire 42 days after being stored at room temperature. The failure to label these medications properly could lead to residents not receiving the intended therapeutic effects or experiencing harmful side effects from expired medications.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, the facility did not label and date leftover food items in the walk-in cooler, and expired food products were found stored in the food pantry. These practices could potentially expose residents to food-borne illnesses and food contamination. During an observation and interview with the Dietary Manager, it was noted that the cooler contained expired food products, including sour cream, cottage cheese, and pimento cheese, all past their best-by dates. Additionally, the dry goods storage area contained expired items such as high-calorie protein supplements, chipotle containers, and imitation coconut extract. The Dietary Manager acknowledged that all food items removed from their original containers should be labeled and dated, and while dairy products past their best-by dates could still be used, they should not be used if they smelled bad. The facility's Corporate Dietitian confirmed that the terms 'used by' and 'best by' were used interchangeably in the company's policy, allowing the Dietary Manager to determine their application. The facility's policy emphasized maintaining storage areas in an orderly manner to preserve food condition, requiring open packages to be stored in sealed and dated containers.
Failure to Administer Medications Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, identified as Resident #300, upon her admission. Resident #300, a female with severe cognitive impairment due to Alzheimer's Disease and Vascular Dementia, was admitted to the facility with a requirement for specific medications to manage her conditions, including anxiety and depression. However, on the day of her admission, she did not receive her prescribed medications, which included Buspirone, Mirtazapine, and Depakote, as documented in her March Medication Administration Record (MAR). The failure to administer these medications was noted in the doctor's progress notes the following day. Interviews with facility staff, including the Director of Nursing (DON) and administrators, revealed that the charge nurse was responsible for ensuring medication administration, and there were systems in place to obtain medications from an emergency kit or automated dispensing system if needed. Despite these systems, the medications were not administered, and the DON could not provide an explanation for this oversight. The facility's policy on medication administration emphasized the importance of administering medications at the first scheduled time following a resident's arrival, which was not adhered to in this case.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from abuse and did not ensure adequate supervision, particularly for a resident with a known history of behavioral issues. On the day in question, a resident with severe cognitive impairment and psychiatric diagnoses, who was care planned for 1:1 supervision due to a risk of physical behaviors, slapped another resident in the face. This incident was witnessed by staff and confirmed by resident statements and written accounts. The same resident was later involved in a second incident the same day, where she slapped another resident during a meal, despite being on 1:1 supervision at the time. Staff interviews and documentation revealed confusion and lack of clarity regarding who was responsible for the 1:1 supervision, with some staff unable to recall the incident or who was assigned to monitor the resident at critical times. The affected residents included individuals with significant cognitive and physical impairments, such as Alzheimer's disease, schizophrenia, anxiety, and muscle weakness. One resident was observed holding her face after being slapped, while another was unable to recall the incident but was assessed as calm and without injury. Staff assessments and interviews indicated that the residents involved were at their baseline following the incidents, but the events were distressing enough to prompt immediate staff intervention and notification of nursing and administrative leadership. Family members present during one of the incidents confirmed that staff were not in the room at the time of the abuse and only responded after being called for help. Documentation and interviews with staff, including CNAs, LPNs, the DON, and the Assistant Business Office Manager, revealed inconsistencies in the implementation and monitoring of the 1:1 supervision protocol. The monitoring chart showed gaps and changes in staff responsible for supervision, and some staff were unclear about their roles or unable to recall the events. The facility's policies required interventions and care planning to prevent further occurrences, but the lack of effective supervision and unclear staff responsibilities directly contributed to the residents being exposed to abuse and placed at risk of harm.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices during medication administration for three residents. Medication aide (MA) A was observed eating food on the medication cart, with a blood pressure cuff and thermometer placed next to the food, and a cup of uncovered pudding on the cart. After eating, MA A did not sanitize his hands, the cart, or the blood pressure cuff before proceeding to administer medications. He also failed to wear gloves, wash hands, or use hand sanitizer between residents, and did not sanitize the blood pressure cuff between uses. During medication administration, MA A handled medications and equipment without proper hand hygiene, including crushing medications and brushing spilled medication off the cart onto the floor with his hand. He used a bed remote that had been on the floor to adjust residents' beds and continued to handle medications and equipment without changing gloves or sanitizing his hands. MA A also kept gloves on while retrieving items from his pocket and picking up objects from the floor, further compromising infection control. Interviews with MA A and the Director of Nursing (DON) confirmed that these actions were not in accordance with facility policy, which requires hand hygiene before and after eating, after contact with residents or equipment, and after removing gloves. The facility's policies also mandate that the medication cart and surrounding work area remain clean at all times. These failures were observed for residents with significant medical conditions, including chronic kidney disease, diabetes, dementia, encephalopathy, epilepsy, and hypertension.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of her needs, specifically regarding the accessibility of a call light. The resident, who was cognitively intact but required partial to moderate assistance with activities of daily living due to conditions such as hemiplegia and hemiparesis, was found without a call light within reach. During an observation, the resident expressed discomfort and frustration as she was unable to find her call bell and had been saturated with urine for over an hour without assistance. The call light system was not functioning, and the resident was given a manual bell, which was placed out of her reach on a bedside dresser. Staff interviews revealed a lack of adherence to the facility's protocol for ensuring call lights were within residents' reach, especially given the non-functioning call light system. CNA A, who was responsible for the resident's care, admitted to not checking if the call bell was accessible and had not entered the resident's room since the start of her shift. Other staff members, including LVNs and CNAs, also failed to ensure the call bell was within reach, despite being trained to conduct 15-minute checks due to the call light system outage. The facility's policy required that call signals and needed items be placed within residents' reach, and staff were responsible for ensuring this. However, multiple staff members, including the DON and Activities Director, acknowledged the oversight in not verifying the call bell's placement. This deficiency in care placed the resident at risk of not receiving timely assistance, as she was unable to call for help when needed.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident who was unable to perform activities of daily living independently. The resident, who was cognitively intact and required partial to moderate assistance with ADLs, was found to be soaking wet with urine, along with her bed sheets and temporary bed pad. The resident expressed discomfort and frustration, stating she had been saturated with urine for over an hour. The call light system was not functioning, and the resident's manual call bell was not within reach, which contributed to the delay in receiving care. Staff interviews revealed that the CNAs and nurses were responsible for checking on residents every 15 minutes due to the non-functioning call light system. However, the staff failed to adhere to this protocol. One CNA assumed another staff member had checked on the resident, while another CNA was focused on delivering breakfast trays and did not verify the resident's call bell was accessible. The LVN on duty also did not check the resident's condition during her rounds, only verifying the resident was in bed from the doorway. The Director of Nursing confirmed that staff were trained to ensure timely incontinent changes and that call bells should be within reach. The facility's policies on perineal care and resident rights emphasize the importance of providing comfort and ensuring call signals are accessible. The failure to provide timely care and maintain the resident's dignity and comfort was a direct result of staff inaction and lack of adherence to established protocols.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards and provided adequate supervision to prevent accidents. This deficiency was identified when a CNA provided incontinence care to a resident who required assistance from two staff members, resulting in the resident rolling off the bed and sustaining a right femur fracture. The incident occurred because the CNA mistakenly believed the resident was a one-person assist and did not check the Kardex for the correct assistance level. The resident involved was an elderly female with multiple medical conditions, including cognitive communication deficit, muscle weakness, vascular dementia, osteoporosis, and Alzheimer's disease. She was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder. The resident's care plan indicated she was at risk for falls and required two staff members for bed mobility, which was not adhered to during the incident. Interviews with staff revealed a lack of awareness and understanding of the resident's care requirements, as some CNAs were unsure of the assistance level needed for the resident. The facility's policy on safe patient handling was not followed, as the CNA did not verify the resident's assistance needs in the Kardex, leading to the accident. This oversight placed the resident at risk for injury and required hospitalization for surgical intervention.
Failure to Notify Physician of Resident's Rash
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's physical condition. Specifically, the facility did not notify the physician when a resident developed a rash on her arms, legs, and back. This oversight was identified during a review of records and interviews, which revealed that the resident had been experiencing itching and scratching for some time, yet the physician was not informed in a timely manner. The resident, an eighty-five-year-old woman with dementia, anxiety disorder, malnutrition, and hypertension, had a history of skin issues. Despite this, the facility's records showed that the rash was not communicated to the physician or family, as indicated in the weekly skin assessments. The resident was receiving treatments such as Zyrtec and Eucerin cream for itching, but these were not new interventions, and the rash persisted without proper notification to the physician. Interviews with staff, including LVNs and the DON, revealed a lack of communication and documentation regarding the resident's condition. The DON was unaware of the rash until it was brought to her attention by the State Investigator. The facility's policy required immediate notification of the physician in case of significant changes, but this protocol was not followed, leading to a delay in appropriate medical intervention for the resident.
Failure to Conduct Timely Skin Assessments Leads to Rash Development
Penalty
Summary
The facility failed to conduct comprehensive and timely skin assessments for a resident, leading to the development of an unexplained rash. The resident, an eighty-five-year-old woman with dementia, anxiety disorder, malnutrition, and hypertension, was not given weekly skin assessments for two weeks. This lapse in care resulted in the resident developing a rash that was not promptly identified or treated, as evidenced by the lack of documentation and communication with the physician or family. The resident's medical records indicated that she had a history of skin issues, including a rash noted in previous assessments. Despite this, the facility did not maintain consistent skin assessments, and the rash was not reported to the physician or family. Interviews with staff revealed a lack of awareness and communication regarding the resident's condition, with some staff assuming the resident's itching and scratching were normal behaviors. The DON admitted to not having conducted any in-services on skin assessments or changes in condition since starting at the facility. The deficiency was further compounded by the absence of a clear protocol for reporting and documenting changes in skin condition. Staff interviews highlighted inconsistencies in performing and documenting skin assessments, with some staff unaware of the resident's rash until it was observed by the WCN and physician. The facility's failure to adhere to its own schedule for skin assessments and the lack of a policy on skin assessments contributed to the delay in addressing the resident's medical needs.
Elopement of Two Residents Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, resulting in the elopement of two residents from the memory care unit. Resident #4, who had a history of dementia and was at risk for elopement, managed to leave the facility on two separate occasions. On the first occasion, she was found outside the facility by a staff member from a nearby business. The facility's records indicated that the doors were not properly secured, which allowed her to exit. On the second occasion, Resident #4 was again found missing from the unit, indicating a lack of adequate supervision and monitoring. Resident #5, who also had a history of dementia and was identified as an elopement risk, managed to leave the facility on the same day as Resident #4's second elopement. The facility's investigation revealed that the residents were able to exit through unsecured doors, which were supposed to be locked and alarmed. The staff failed to adequately monitor the residents and respond to door alarms, which contributed to the residents' ability to leave the secure unit. Interviews with staff members, including CNAs and nurses, highlighted inconsistencies in the facility's procedures for monitoring residents and responding to door alarms. Staff members reported that they were expected to conduct rounds and headcounts, but there was no specific policy in place to ensure these were done consistently. Additionally, the facility's doors were found to disengage during power outages, further compromising the security of the memory care unit. These lapses in supervision and security measures led to the residents' elopements, posing a risk to their safety.
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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