Vintage Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Denton, Texas.
- Location
- 205 N Bonnie Brae, Denton, Texas 76201
- CMS Provider Number
- 675939
- Inspections on file
- 46
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18 (2 serious)
Citation history
Health deficiencies cited at Vintage Health Care Center during CMS and state inspections, most recent first.
Multiple lists containing sensitive medical information, such as oxygen use, Foley catheters, dialysis, g-tubes, and pacemakers, were left unattended and visible on a nurse's cart, exposing residents' last names and medical details. Additionally, a medication blister pack with a resident's full name and prescription information was left on a medication cart. Staff interviews confirmed that these actions failed to maintain confidentiality of residents' medical records as required by facility policy.
Staff failed to properly store medications and biologicals, leaving medicated creams, a nebulizer solution, and a topical pain reliever unsecured in the rooms of four residents with various medical conditions. These items were found on drawers and side tables, accessible to residents, in violation of facility policy and regulatory requirements. Staff interviews confirmed that medications should not have been left in resident rooms and that proper storage procedures were not followed.
A resident with COPD was found with a nebulizer breathing mask left unbagged on a shelf when not in use, contrary to infection control expectations. Nursing staff confirmed the mask should have been stored in a clean plastic bag, and the facility's policy emphasized infection prevention, but a specific policy on mask storage was not available during the survey.
A deficiency was cited when a resident's care plan was found to be incomplete, lacking measurable timetables and specific actions to address all identified needs. Surveyors observed that the care plan did not fully document or plan for the resident's care requirements as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
Surveyors found that the facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency related to infection control practices.
A resident with severe cognitive impairment and legal blindness was found without access to her call light, which had been left on a shelf out of reach after care was provided. Staff interviews confirmed the expectation that call lights should always be accessible, and leadership acknowledged that all staff are responsible for ensuring this. The resident's care plan required the call light to be within reach and its location communicated to her due to her blindness.
Two residents requiring oxygen therapy did not receive care consistent with professional standards: one received oxygen through a nasal cannula connected to an empty humidifier bottle, resulting in nasal dryness, while another's nasal cannula was improperly stored unbagged in a drawer, exposing it to contamination. Staff failed to notice these issues during routine rounds, despite facility policy requiring humidification and proper storage of respiratory equipment.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a comprehensive care plan for an indwelling Foley catheter, despite physician orders and facility policy requiring such planning. The resident was observed with improper catheter management, and staff confirmed that care plans should be updated but were not in this case.
Two residents who were dependent on staff for ADLs did not receive necessary nail care, resulting in one having long, dirty fingernails and another with long, cracked toenails. Despite care plans specifying regular nail care and podiatry referrals for diabetic residents, staff did not perform or arrange for these services as required.
A resident with severe cognitive impairment and an indwelling Foley catheter was observed with the catheter drainage bag on the floor and the tubing not properly secured to her leg. The care plan lacked instructions for catheter care, and staff confirmed these practices did not meet facility policy, which requires catheter bags and tubing to be kept off the floor and properly secured.
A resident with dementia and a history of wandering risk eloped from the facility within hours of admission due to incomplete elopement risk assessment and lack of adequate supervision. The resident was missing for approximately two hours before being found by law enforcement and returned to the facility.
A facility failed to notify a physician of changes in a resident's surgical site, leading to an infection and hospitalization. The Treatment Nurse noticed drainage but did not inform the surgeon, and the task was improperly delegated. The attending physician and nurse practitioner were not informed, and documentation was lacking, resulting in a significant oversight in care.
A facility failed to monitor and report a resident's surgical site condition, leading to an infection requiring hospitalization. The resident, with a history of back and pelvis surgery, did not have a baseline care plan addressing surgical care needs. Staff interviews revealed a lack of communication and documentation regarding the resident's condition, and the facility's policy on notifying physicians of changes in status was not followed.
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper sanitation practices. A blood pressure device was not sanitized between use on two residents, and staff failed to use hand sanitizer while distributing lunch trays. These lapses in practice indicate a failure to adhere to established protocols, potentially putting residents at risk of illness.
A facility failed to ensure a resident received proper care to prevent the re-development of a pressure ulcer on her right heel. Despite physician orders for a pressure off-loading boot, the resident was observed without it. The resident's nurse aide was unaware of the requirement, and the resident's nurse confirmed the protector should have been in place. The Treatment Nurse and DON emphasized the importance of the heel protector, as per facility policy.
A resident at risk for falls did not have their fall mat properly placed, as observed during a survey. The resident, with a history of dementia and other conditions, was found in bed without the fall mat on the floor, contrary to their care plan. Staff acknowledged the oversight and corrected the mat's placement, highlighting a lapse in following the facility's fall prevention policy.
A facility failed to develop a baseline care plan within 48 hours of admission for a resident with multiple medical conditions, including a surgical incision site that required care. The plan lacked necessary instructions for surgical site care, placing the resident and staff at risk due to inadequate communication and continuity of care. The oversight was attributed to the facility's policies not addressing surgical site care and the DON's recent start in her role.
The facility failed to maintain an effective pest control program, leading to a gnat infestation in the kitchen and dining hall. Despite a pest control visit a week prior, the treatment was ineffective, and staff interviews revealed the issue had persisted since the start of summer. The maintenance director prioritized other issues over the gnat problem, delaying the installation of recommended bug lights.
Failure to Protect Resident Privacy and Confidentiality of Medical Information
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of residents' personal and medical information for fifteen out of twenty-five residents reviewed. Multiple lists containing sensitive medical information, such as residents using oxygen, those with Foley catheters, on dialysis, with g-tubes, and with pacemakers, were left unattended and visible on top of a nurse's cart in the hallway. These lists included residents' last names and specific medical interventions or devices, making the information accessible to anyone passing by, including unauthorized individuals. Additionally, a medication blister pack containing a resident's full name, medication details, prescription number, physician's name, and pharmacy information was left unattended on top of a medication cart outside the nurses' station. Observations confirmed that the paper with residents' last names and medical interventions was left in plain view on a nurse's cart, and staff interviews revealed uncertainty about who placed the paper there. The Assistant Director of Nursing (ADON) initially stated that the list was not considered a HIPAA violation because it only included last names, but did not respond when asked if the medical information itself was confidential. The Director of Nursing (DON) acknowledged that the information was medical in nature and should have been kept confidential, regardless of the circumstances that led to it being left out. Further interviews with staff, including the medication aide and the ADON, confirmed that the blister pack left on the medication cart was considered a HIPAA violation due to the presence of identifiable and confidential information. Staff admitted that the information should have been secured or at least flipped over to prevent exposure. The facility's policy on resident rights explicitly states that residents have the right to personal privacy and confidentiality of their personal and medical records, which was not upheld in these instances.
Failure to Securely Store Medications and Biologicals
Penalty
Summary
Facility staff failed to store drugs and biologicals in locked compartments as required by state and federal regulations. During observations, surveyors found that medicated creams (zinc oxide), a vial of nebulizer solution, and a tube of topical pain reliever were left inside the rooms of four residents. These items were visible and accessible on top of drawers or side tables, rather than being secured in medication carts or locked storage. Staff interviews confirmed that these medications were not supposed to be left in resident rooms and should have been removed after use. The residents involved had various medical conditions, including hemiplegia, hemiparesis, dementia, incontinence, chronic obstructive pulmonary disease, and pain management needs. All residents were cognitively intact according to their BIMS scores. The medications found included zinc oxide for incontinence care, a solution for breathing treatments, and a topical pain reliever for shoulder pain. Staff members acknowledged that these medications were left in the rooms after care was provided and that they did not notice them during their rounds. Interviews with CNAs, an LVN, the ADON, and the DON revealed a lack of adherence to the facility's medication storage policy, which requires all medications and biologicals to be stored securely and only accessible to authorized personnel. Staff admitted they did not know who left the medications in the rooms and recognized that medications should not be left accessible to residents. The facility's policy, reviewed by surveyors, clearly states that medications must be stored safely and securely, accessible only to licensed nursing or authorized staff.
Failure to Properly Store Nebulizer Breathing Mask
Penalty
Summary
A deficiency was identified when a resident with chronic obstructive pulmonary disease (COPD) was observed to have a nebulizer breathing mask left unbagged on a shelf in his room when not in use. The resident, who was cognitively intact and had physician orders for as-needed nebulizer treatments, stated he would use the breathing treatment if experiencing shortness of breath but could not recall the last time it was used. During the observation, the mask was not stored in a clean plastic bag as required for infection control. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that the expectation was for breathing masks to be bagged when not in use to prevent contamination and infection. The LVN admitted she had not noticed the unbagged mask during her morning rounds and was unsure when it was last used. The facility's policy on oxygen administration included goals for safe delivery and infection prevention, but a specific policy on bagging the breathing mask was not provided at the time of the survey.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process, where it was noted that the care plan did not comprehensively cover the resident's needs as required.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence or inadequacy of a program designed to prevent and control infections within the facility, as required by regulatory standards.
Failure to Ensure Call Light Accessibility for Resident with Visual and Cognitive Impairment
Penalty
Summary
The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding the accessibility of the call light system. The resident involved was an elderly female with diagnoses including spondylosis and legal blindness, and she was severely cognitively impaired, requiring significant assistance with daily activities. Her care plan included an intervention to keep the call light within her reach and to inform her of its location due to her visual impairment. On the day of the survey, the resident was observed in bed with her call light placed on a shelf out of her reach. When asked, she was unaware of the call light's location and was unable to find it herself. Staff interviews confirmed that the call light should always be within reach, especially for residents with significant impairments. A nurse and a CNA both acknowledged that the call light was not accessible and that it was their responsibility to ensure it was placed appropriately after providing care. Further interviews with facility leadership, including the DON, Administrator, and ADON, confirmed the expectation that all staff are responsible for ensuring call lights are within reach of residents before leaving the room. The facility's policy on resident rights also states that residents have the right to reasonable accommodation of their needs and preferences, which includes access to communication devices such as call lights.
Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring oxygen therapy. For one resident with chronic obstructive pulmonary disease (COPD) and moderate cognitive impairment, observations revealed that the humidifier bottle attached to his oxygen concentrator was empty while he was receiving oxygen via nasal cannula. The resident reported nasal dryness and could not recall when the bottle last contained water. The assigned LVN admitted to not noticing the empty humidifier during morning rounds and only refilled it after the deficiency was identified. For another resident with COPD and severe cognitive impairment, her nasal cannula, used for nighttime oxygen therapy, was found unbagged and stored directly inside a drawer, with the prongs in contact with other items. The resident confirmed that staff typically removed the cannula in the morning. The LVN acknowledged that the cannula should have been stored in a plastic bag to maintain cleanliness and prevent infection, but had not noticed its improper storage during rounds. Upon discovery, the LVN discarded the unbagged cannula and planned to replace it. Interviews with the DON, Administrator, and ADON confirmed that facility expectations and policy require humidifier bottles to contain water during oxygen administration and nasal cannulas to be bagged when not in use. The facility's policy on oxygen administration specifies the need for humidification to prevent drying of mucous membranes. Despite these expectations, staff failed to ensure proper respiratory care practices for both residents.
Failure to Develop and Implement Foley Catheter Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling Foley catheter, as required by federal regulations. Despite the resident's significant medical history, including cancer, cerebrovascular accident, metabolic encephalopathy, and severe cognitive impairment (BIMS score 5/15), there was no care plan addressing the management and care of the Foley catheter. The resident had physician orders for specific catheter care, including monthly changes, care every shift, and monitoring for complications, but these were not reflected in the resident's comprehensive care plan. Observations and record reviews revealed that the resident was confused, unable to respond to questions, and had a Foley catheter drainage bag improperly positioned on the floor with the catheter strap detached. Interviews with the DON and Administrator confirmed that care planning is a team responsibility and should be updated upon admission and with any change in condition. Facility policies also require daily review of care plans for changes, but this was not done for the resident's Foley catheter, resulting in the deficiency.
Failure to Provide Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) related to nail care for two residents who were dependent on staff. One resident, a male with a history of cerebrovascular accident, muscle weakness, and moderate cognitive impairment, was observed with long fingernails containing brown matter underneath. He reported that he had requested staff assistance to clean and trim his nails, but this was not done. His care plan included interventions for nail care to be performed on bath days and as needed, but these interventions were not followed. Another resident, a male with diabetes, anxiety, bipolar disorder, and schizophrenia, was found to have long, cracked toenails. He was totally dependent on staff for ADLs and was unsure who could safely trim his toenails due to his diabetic condition. His care plan specified that nail care, particularly for diabetic residents, should be provided by a nurse, and a podiatry consult was available as needed. Observations and interviews with staff confirmed that nail care responsibilities were not carried out as required, and the process for referring diabetic residents for podiatric care was not followed.
Failure to Provide Proper Catheter Care and Prevent UTI
Penalty
Summary
A resident with a history of cancer, cerebrovascular accident, metabolic encephalopathy, and anxiety, who was severely cognitively impaired, was readmitted to the facility with an indwelling Foley catheter. The physician's orders specified monthly catheter changes, catheter care and drainage bag emptying every shift, and monitoring for complications, with instructions to ensure the catheter strap was in place and holding. However, the resident's comprehensive care plan did not include any plan for indwelling Foley catheter care. During observation, the resident was found lying in bed with the Foley catheter drainage bag placed on the floor and the catheter tubing inadequately secured to her leg, as the catheter strap had come off and was draped over the catheter. Nursing staff confirmed that the drainage bag should not be on the floor and the tubing should be properly secured, acknowledging that failure to do so could lead to cross-contamination and infection. Facility policy also required that catheter tubing and drainage bags be kept off the floor and properly secured, but these procedures were not followed in this instance.
Failure to Prevent Elopement Due to Incomplete Admission Assessments and Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate monitoring, supervision, and implementation of assistive devices to prevent accidents for a resident with dementia who was newly admitted. The resident, who had a history of impaired cognitive function, risk for falls, and was at risk for wandering, was admitted from a short-term general hospital. Upon admission, the resident was oriented to his room and directed to the dining area for lunch. After lunch, he was last seen at the nurse's station and later in his room unpacking. Within approximately two hours and twenty minutes of admission, the resident could not be located, and a code orange was initiated. The facility did not identify potential hazards or follow internal systems in place to prevent the resident's elopement. The required elopement risk assessment and other admission assessments had not been completed at the time of the incident, as the resident eloped before the four-hour window for completing these assessments. The facility's leadership team had reviewed pre-admission clinical documents but did not find concerning information related to wandering or elopement risk, and the secured unit available was female-only, which influenced the admission decision. The resident was missing for approximately two hours before being located by local law enforcement about a mile from the facility. Interviews with staff confirmed that the resident did not express a desire to leave or appear confused immediately prior to the incident. The facility's policy required an elopement risk assessment upon admission, but this was not completed before the resident's elopement. The failure to complete timely assessments and implement appropriate safety measures resulted in the resident's unsupervised exit from the facility.
Failure to Notify Physician of Surgical Site Changes
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident representative of a significant change in the resident's physical status. This deficiency was identified in the case of a post-operative resident who had undergone back and pelvis surgery. The resident's surgical incision site showed signs of drainage, which was not promptly reported to the attending physician or surgeon, leading to an infection that required hospitalization and further surgical intervention. The report details that the facility's Treatment Nurse noticed the drainage from the surgical site and informed the facility's wound care doctor, who was not the resident's provider. The wound care doctor advised the Treatment Nurse to notify the surgeon, but this was not done. The Treatment Nurse delegated the task of notifying the surgeon to another nurse, who did not follow through. As a result, the resident's condition worsened, and the infection led to a return to the hospital for additional surgery. Interviews with various staff members revealed a lack of communication and documentation regarding the resident's condition. The attending physician and the nurse practitioner were not informed of the changes in the resident's incision site, and there was no documentation of any assessment or notification to a provider about the incision site drainage. The facility's Director of Nursing and Administrator acknowledged the failure to notify the surgeon and the attending physician, which was crucial for infection control and the resident's safety.
Removal Plan
- 100% skin sweep of all residents completed by the DON, ADON, and Charge Nurses.
- All residents with wounds including surgical wounds were assessed by the DON for potential decline in wound status. No acute changes noted.
- Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e., new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified.
- All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site. DON/designee to monitor weekly for compliance.
- All surgical wounds/incisions changes or decline in condition will be reported to the surgeon of the incision site and attending physician. DON/designee to monitor weekly for compliance.
- DON/designee to ensure surgeon contact information is available in resident's EMR upon admission. DON/designee to monitor weekly for compliance.
- DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds. DON/designee to monitor weekly for compliance.
- Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect.
- The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds. The DON or Designee will ensure that the wound was assessed and notification to the Attending MD as well as the Surgeon was completed timely.
- An ADHOC QAPI meeting was completed to include the IDT team and Medical Director.
- The following in-services were initiated by the DON, ADON and regional nurse. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation prior to taking an assignment. All agency staff will be in-serviced prior to their scheduled shift.
- All Charge Nurses: Notification of Change in Condition Policy- Reporting changes in condition involving wounds to the physician, nurse practitioner, or surgeon - i.e. new wound or decline of a current wound. If the change in condition involves a surgical wound, the surgeon will also be notified immediately for any additional orders. If a LVN or RN Charge Nurse does not assess or notify the physician timely, the DON or Administrator will be notified.
- Non-licensed nursing staff: Abuse and Neglect Policy- failure to report a change in condition on a resident such as a new or worsening wound, could be considered neglect.
- Notification of Change in Condition Policy- Reporting negative changes in condition involving wounds to the charge nurse immediately. Changes include a soiled dressing, foul odor, redness, or complaints of pain to the wound. If the charge nurse is not available, the DON or ADON will be notified.
Failure to Monitor and Report Surgical Site Condition
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive resident-centered care plan for a resident who was reviewed for quality of care. The facility did not ensure that physician orders for treatment, care, and monitoring of the resident's surgical site incision were obtained upon admission, which resulted in a subsequent infection that required hospitalization and surgical intervention. Additionally, the facility did not complete or document any skin/incision/wound assessments of the resident's surgical incision site, leading to the infection. The resident, a cognitively intact female with a BIMS score of 15, was admitted to the facility with relevant diagnoses including metabolic encephalopathy, subluxation of lumbar vertebra, wedge compression fracture of thoracic vertebrae, protein-calorie malnutrition, anxiety, and major depressive disorder. Despite having undergone back and pelvis surgery prior to admission, the facility's baseline care plan did not address the resident's surgical care needs. There was no evidence of surgical site assessment, treatment, or care documentation in the resident's records, and physician orders for monitoring the surgical site were not observed for the month of September. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's surgical site condition. The treatment nurse reported the incision site drainage to a wound care doctor, who was not the resident's provider, and delegated the responsibility to notify the surgeon to another nurse, who did not recall being asked to do so. The attending doctor and nurse practitioner were not informed of any incision site changes or concerns, and the facility's policy on notifying physicians of changes in status was not followed. This failure to monitor and report changes in the resident's condition led to a delay in medical intervention and a decline in the resident's health, resulting in hospitalization and further treatment.
Removal Plan
- 100% skin sweep of all residents completed by the DON, ADON, and Charge Nurses.
- All residents with wounds including surgical wounds were assessed by the DON for potential decline in wound status.
- The Administrator and DON were in-serviced 1:1 on Notification of Change in Condition Policy.
- All surgical wounds are to be monitored daily by nurse, any changes or decline will be reported to attending physician and surgeon of incision site.
- All surgical wounds have treatment orders, upon admission.
- All skin assessments, upon admission and weekly reflect any surgical incision.
- DON/designee to monitor new surgical incision resident orders during daily stand up to ensure treatment orders are in place and admission assessment includes surgical incisions.
- DON/designee to ensure surgeon contact information is available in resident's EMR upon admission.
- DON/designee completed in-service of all nurses on SBAR change of condition for surgical wounds.
- Abuse and Neglect Policy to include failure to assess a wound and/or notify a physician for a change in condition on a wound including surgical wounds, could be considered neglect.
- The DON or Designee will review the clinical dashboard daily for any documentation that notes a change in condition in wounds including surgical wounds.
- An ADHOC QAPI meeting was completed to include the IDT team and Medical Director.
- All Charge Nurses were in-serviced on monitoring surgical wounds daily and reporting changes, ensuring treatment orders are in place, and updating baseline care plans.
- Non-licensed nursing staff were in-serviced on Abuse and Neglect Policy and Notification of Change in Condition Policy.
Infection Control Lapses in Equipment and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two specific incidents involving improper sanitation practices. In the first incident, a Medical Assistant (MA) did not sanitize a blood pressure measurement device between its use on two residents. The device was used on a male resident with multiple health issues, including major depressive disorder, type 2 diabetes, and hemiplegia, and a female resident with dementia, chronic kidney disease, and heart disease. The MA acknowledged the oversight during an interview, and the Director of Nursing (DON) confirmed that the device should have been sanitized between uses to prevent infection spread. In the second incident, a Registered Nurse (RN) and a Certified Nursing Assistant (CNA) failed to use hand sanitizer while distributing lunch trays to residents. The RN was observed placing trays in front of residents without sanitizing hands between each tray, and the CNA was instructed by a corporate staff member to sanitize hands after passing multiple trays without doing so. Both staff members acknowledged the importance of hand hygiene to prevent cross-contamination, and the DON reiterated the expectation for staff to use hand sanitizer before and after handling each tray. The facility's policies on infection control and hand hygiene emphasize the importance of sanitizing reusable equipment and performing hand hygiene to prevent infection transmission. Despite regular in-service training on these procedures, the observed lapses in practice indicate a failure to adhere to established protocols, potentially putting residents at risk of illness and exposure to communicable diseases.
Failure to Ensure Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #44, received appropriate care to prevent the re-development of a pressure ulcer on her right heel. Despite physician orders to use a pressure off-loading boot every shift, Resident #44 was observed without her heel protector while resting in bed. The heel protectors were found on a table at the foot of her bed, and instructions for their use were posted above them. The resident's nurse aide was unaware of the requirement for the heel protector and had to consult with the resident's nurse, LVN Z, who confirmed that the heel protector should have been in place. Further interviews revealed that the Treatment Nurse emphasized the importance of the heel protector in preventing the reopening of the resident's previously stage four pressure wound, which had since closed. The Director of Nursing (DON) also stated that it was expected for the nursing staff to ensure the use of pressure-relieving devices as per physician orders. The facility's policy on skin integrity management highlighted the need for additional heel protection, yet this was not adhered to, leading to the deficiency.
Failure to Ensure Fall Mat Placement for Resident at Risk
Penalty
Summary
The facility failed to ensure that a fall mat was appropriately placed for a resident identified as a fall risk. On the date of observation, the fall mat intended to prevent injury was found folded and not in use on the floor beside the resident's bed. The resident, who was admitted from an acute care hospital and was on hospice, had a history of dementia, anxiety disorder, pain, and a pressure ulcer. The comprehensive care plan for the resident included the use of a fall mat as a precautionary measure due to her impaired visual function, communication problems, and risk for falls related to dementia, poor balance, and weakness. During the observation, the resident's nurse aide acknowledged the resident's fall risk and corrected the placement of the fall mat upon noticing it was not in use. The Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) both confirmed that the fall mat should be in place while the resident was in bed to minimize the risk of injury. The facility's policy on preventative strategies to reduce fall risk and comprehensive care planning emphasized the importance of implementing individualized care plans to prevent falls, which was not adhered to in this instance.
Failure to Develop Baseline Care Plan for Surgical Site Care
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, which is a requirement to ensure effective and person-centered care. The resident, a cognitively intact female with multiple medical conditions including metabolic encephalopathy, spinal issues, malnutrition, anxiety, and depression, was admitted to the facility and required substantial assistance with mobility and personal care. Despite these needs, the baseline care plan did not include necessary instructions for surgical incision site care, which was a critical aspect of her immediate care requirements. The deficiency was identified through interviews and record reviews, which revealed that the baseline care plan provided to the resident did not document any assessment, treatment, or care instructions for her surgical incision site. The facility's administrator and Director of Nursing (DON) acknowledged the oversight, with the DON noting that she had just started her role at the time of the resident's admission. The facility's policies on baseline care plans and skin integrity management did not specifically address surgical site care, contributing to the oversight. The lack of a comprehensive baseline care plan placed both the resident and facility staff at risk by not ensuring continuity of care and communication among staff, which is crucial for resident safety and preventing adverse events shortly after admission. The facility's failure to include surgical site care in the baseline care plan was a significant oversight, as it did not meet professional standards of quality care and left the resident's immediate needs unaddressed.
Facility Fails to Control Gnat Infestation in Kitchen and Dining Hall
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats in both the kitchen and dining hall. During an observation, at least 20 gnats were seen in the kitchen, and 12 gnats were observed in the dining hall while residents were eating lunch. The facility's pest control log indicated that a pest control company had visited the facility a week prior to treat for flies, fruit flies, and gnats in various areas, including the kitchen and dining hall. However, the treatment was ineffective in eliminating the gnats. Interviews with staff revealed that the gnats had been an ongoing issue since the start of summer. The kitchen staff had informed the maintenance department about the problem, but the maintenance director had prioritized other issues, such as a gas leak and plumbing problems, over addressing the gnat infestation. Although the pest control company recommended using bug lights, they had not been installed until the day of the observation. The facility's policy on insect and rodent control was undated, but it stated that arrangements should be made with a reputable company for regular spraying for insects, including rodent control when required.
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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