Weslaco Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Weslaco, Texas.
- Location
- 422 E 18th St, Weslaco, Texas 78596
- CMS Provider Number
- 676037
- Inspections on file
- 29
- Latest survey
- November 19, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Weslaco Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with Alzheimer's Disease and severe cognitive impairment developed a new skin tear, but staff failed to perform a required head-to-toe skin assessment immediately after its discovery. Although the injury was reported among staff, no one completed the comprehensive assessment as outlined in facility policy, resulting in incomplete documentation and delayed evaluation of the resident's overall skin condition.
A resident with hypertension and moderate cognitive impairment was given nifedipine by an LVN even though her heart rate was below the ordered threshold, contrary to physician orders and facility policy. There was no documentation that the nurse or physician was consulted prior to administration.
A resident with multiple cardiac conditions had an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form that was not fully completed, as it lacked the required physician's signature. Although the resident and responsible parties had signed the form and the DNR status was reflected in the care plan and electronic records, staff acknowledged the form was incomplete without the physician's signature. The process for obtaining the signature was delayed, and the incomplete form was still placed in the nurse's station binder.
A resident with multiple diagnoses, including dementia and gait abnormalities, experienced a witnessed fall that was documented in the care plan and progress notes. However, the fall was not coded in the discharge MDS assessment, as required, due to a breakdown in communication between nursing staff and the MDS department. This resulted in the resident's fall not being accurately reflected in the official assessment.
The facility did not update or implement comprehensive care plans for two residents, omitting a dementia diagnosis for one and failing to include antibiotic treatment for pneumonia for another. Staff interviews and record reviews confirmed that care plans were not promptly revised to reflect new diagnoses or treatments, contrary to facility policy and regulatory requirements.
A resident was administered Seroquel, an antipsychotic, without a proper supporting diagnosis, as the documented condition was dementia without behavioral or psychotic disturbances. Nursing staff and the ADON acknowledged that lewy body dementia alone is not an appropriate indication for antipsychotic use, and facility policy requires psychotropic medications to be used only when nonpharmacological interventions are contraindicated. Despite this, the medication was continued without clear clinical justification.
Surveyors found that a medication cart contained expired famotidine, and interviews with an LVN, ADON, and DON confirmed that nurses were responsible for checking and removing expired medications. The facility's policy required identification and removal of expired drugs, but this was not followed, resulting in noncompliance with professional standards.
A live roach was observed in a hallway, and staff interviews confirmed that while pest control services are provided monthly and sightings are logged, roaches have still been seen in the facility. The Administrator acknowledged there is no formal pest control policy, and records showed multiple recent roach sightings and treatments.
A resident with severe cognitive impairment experienced an alleged incident of physical abuse during a bed bath by two CNAs, which was reported by a hospice CNA. The facility failed to report the allegation to the State Survey Agency within the required timeframe, as their internal investigation found no substantiated evidence of abuse.
A facility failed to maintain an effective infection control program when a CNA entered a resident's room on contact precautions without donning the required PPE. The resident had an ESBL infection, and despite signage indicating the need for PPE, the CNA did not wear a gown or gloves. Interviews with staff revealed inconsistencies in understanding and following infection control policies.
The facility failed to ensure that physicians acted upon and documented their rationale in response to pharmacist recommendations for three residents, leading to delays in addressing medication evaluations and adjustments.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. During a kitchen observation, 27 gallons of expired water were found in the emergency water supply area. The Dietary Manager and Administrator acknowledged the issue, which violated the facility's Emergency and Disaster Planning policy requiring non-expired water supplies.
The facility failed to limit PRN orders for psychotropic drugs to 14 days without proper physician documentation for a resident with multiple diagnoses, including anxiety and major depressive disorder. The resident received Lorazepam PRN multiple times over two months without a stop date or physician evaluation, despite recommendations from the pharmacy consultant. Staff interviews revealed a lack of timely action on these recommendations, leading to non-compliance with the facility's policy and regulatory requirements.
The facility failed to ensure that two residents' Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were fully and correctly completed, specifically lacking physician signatures. Staff interviews revealed inconsistencies in the process and understanding of obtaining the necessary signatures, and the facility did not have a specific policy concerning DNR forms.
The facility failed to report allegations of abuse involving a resident within the required 24-hour timeframe. An elderly female resident with Alzheimer's and dementia was observed being inappropriately touched by another resident. The incident was not reported immediately, and it was only after the resident's responsible party requested it that the local police and State Survey Agency were notified the following day. The delay in reporting violated the facility's policy and regulatory requirements.
The facility failed to implement a baseline care plan for a resident requiring maximum assistance for eating, leading to her being left hungry and thirsty. Despite hospital orders and an occupational therapy evaluation indicating total dependence, the resident was incorrectly assessed as needing only supervision, resulting in inadequate feeding assistance.
The facility failed to assist a resident with severe malnutrition and other health issues with eating, despite hospital orders indicating she required maximum assistance. Observations and interviews revealed that the resident was left without help during meals, leading to poor nutritional intake. Staff inconsistencies and communication failures contributed to the deficiency.
The facility failed to provide adequate respiratory care for two residents by not administering oxygen at the physician-ordered rate, not setting up suctioning equipment, and not properly documenting oxygen saturation levels. These failures placed the residents at risk of respiratory complications.
A resident was found with a tube of Gelmicin medication on his overbed table, which was brought in by a family member and not prescribed by the physician. Staff were aware but did not report or document the incident, and the resident's care plans did not reflect permission to self-medicate.
A resident with cognitive impairment and multiple medical conditions had family members bring in medication for personal use, which was not documented in the clinical records. Staff were aware but did not report or document the incident, violating the facility's documentation policy.
Failure to Perform Timely Head-to-Toe Skin Assessment After New Skin Tear
Penalty
Summary
A deficiency occurred when staff failed to perform a head-to-toe skin assessment immediately after discovering a new skin tear on a female resident with Alzheimer's Disease and severe cognitive impairment. The resident was identified as being at risk for impaired skin integrity due to incontinence, friction/shear, and decreased mobility, with care plan interventions requiring weekly and as-needed skin inspections. On the day the skin tear was found, the MDS nurse noted the injury and informed the charge nurse, but neither conducted a full head-to-toe assessment as required by facility policy and professional standards. Documentation shows that a skin assessment was not performed on the day the wound was discovered. Interviews with the wound care nurse, MDS nurse, and charge nurse confirmed that all were aware of the need for a comprehensive skin assessment after a new wound is found, but each believed the responsibility lay with another staff member. The facility's policy required detailed documentation of skin assessments, including wound description and other relevant observations, which was not completed at the time of the incident. The deficiency was identified through observation, record review, and staff interviews, with the resident's skin tear later observed to be nearly healed.
Failure to Hold Antihypertensive Medication for Low Heart Rate
Penalty
Summary
A significant medication error occurred when a resident with a history of essential hypertension and a moderate cognitive impairment was administered nifedipine extended release 90 mg, a blood pressure medication, despite her heart rate being below the physician-ordered parameter. The resident's medication order specified that nifedipine should be held if systolic blood pressure was less than 100 or heart rate was less than 60, and the nurse should be notified. On the date in question, the resident's heart rate was recorded at 56, but the medication was still administered by an LVN. Interviews with the LVN and the Director of Nursing (DON) confirmed that the facility's policy and the physician's order required the medication to be held and the nurse or physician to be notified if vital signs were outside the specified parameters. There was no documentation that the LVN consulted with a nurse or physician before administering the medication. The facility's policy on medication administration also required holding medications for vital signs outside prescribed parameters, which was not followed in this instance.
Failure to Obtain Physician Signature on OOH-DNR Form
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form was properly completed, specifically lacking the required physician's signature. The resident in question was a cognitively intact female with multiple cardiac-related diagnoses, including syncope, hypertensive urgency, mitral valve disorder, atrioventricular block, paroxysmal atrial fibrillation, and somnolence. Her care plan and physician orders indicated a DNR status, and the resident had signed the OOH-DNR form, but the attending physician had not signed the document as required. Interviews with facility staff revealed that the process for completing DNR forms involved the social worker providing the form to the resident or family, obtaining necessary signatures, and then forwarding the form to medical records for the physician's signature. Staff acknowledged that the DNR form was not considered complete without the physician's signature, but the form was still placed in the binder at the nurse's station even if incomplete. The medical records staff stated that they attempted to obtain the physician's signature within 24 hours, but in this case, the form remained unsigned by the physician until the surveyor's inquiry. Further interviews with nursing and administrative staff confirmed that the code status was updated in the electronic record system and DNR binder based on the resident or responsible party's signature, even if the physician had not yet signed the form. Staff also indicated that there was no set timeframe for obtaining the physician's signature, and the process could be delayed if the physician was not present in the facility. The facility's policy required that advance directives be supported and facilitated, but the lack of a physician's signature on the OOH-DNR form meant the directive was incomplete at the time of review.
Failure to Accurately Code Resident Fall in MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status, specifically by not coding a witnessed fall that occurred on 3/30/25. Record reviews showed that the resident, who had diagnoses including muscle wasting, lack of coordination, gait abnormalities, dementia, and Alzheimer's disease, experienced a fall that was documented in the incident log, care plan, and progress notes. The care plan and progress notes indicated that the fall was witnessed, and appropriate notifications and monitoring were documented at the time of the incident. Despite this documentation, the discharge MDS assessment did not indicate that the resident had experienced a fall since admission or prior assessment, as required by CMS's RAI Version 3.0 Manual. Interviews with facility staff confirmed that the fall should have been captured in the MDS, and its omission was attributed to a lack of communication between nursing staff and the MDS department. The MDS coordinator acknowledged that the fall was not coded and explained that this could result in incomplete information being communicated to subsequent care providers.
Failure to Update and Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulatory standards. For one resident with a diagnosis of dementia and Alzheimer's disease, the most recent care plan did not include dementia as an active diagnosis, despite the resident's medical record and MDS assessment indicating its presence. Interviews with facility staff revealed that the care plan was not updated to reflect this diagnosis, with staff citing a lack of recent physician documentation and a high BIMS score as reasons for omission. The MDS nurse acknowledged that dementia was included on the MDS due to hospital discharge information but was not care planned because it was not considered an active diagnosis by the physician at the time. Another resident, who was being treated for pneumonia with antibiotics, did not have this treatment reflected in their care plan. The care plan, dated prior to the pneumonia diagnosis and antibiotic order, was not updated to include the new medical intervention. Staff interviews confirmed that the care plan should have been updated immediately upon receipt of the antibiotic order, and failure to do so could impact the delivery of necessary care. The facility's policy requires that care plans be updated promptly to reflect new diagnoses and treatments, but this was not followed in this instance. Record reviews and staff interviews consistently indicated that the lack of timely updates to care plans could result in gaps in communication and care delivery. The facility's own policy mandates the inclusion of measurable objectives and timeframes in care plans to address all identified needs, but these requirements were not met for the two residents in question. The findings demonstrate that the facility did not ensure care plans were current and comprehensive, as required by both internal policy and federal regulations.
Antipsychotic Medication Administered Without Proper Diagnosis
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by administering Seroquel (quetiapine), an antipsychotic medication, without a proper diagnosis supporting its use. The resident in question had a diagnosis of unspecified dementia without behavioral or psychotic disturbances, as well as hallucinations, but the documentation did not indicate behavioral symptoms that would warrant antipsychotic therapy. The care plan and medical records showed the medication was ordered for 'lewy body dementia with behavioral disturbance,' but interviews with nursing staff and the ADON revealed that lewy body dementia alone is not an appropriate diagnosis for antipsychotic use, and staff were aware of the associated risks and black box warning for elderly patients with dementia-related psychosis. Despite the presence of a facility policy stating that psychotropic medications should only be used when nonpharmacological interventions are contraindicated and not for discipline or staff convenience, the medication was continued without clear justification. Staff interviews indicated confusion regarding the appropriateness of the diagnosis for Seroquel, and the DON confirmed that the physician provided the diagnosis but did not clarify the clinical rationale. The resident did not exhibit side effects at the time of review, but the facility did not address the lack of a proper diagnosis for the ongoing use of the antipsychotic medication.
Expired Medication Found on Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to ensure drugs and biologicals were stored and labeled according to professional standards on one of four medication carts. Specifically, a box of famotidine 10mg with an expiration date of 4/2025 was found on the 200 hall nurse's medication cart after its expiration date. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that nurses were responsible for checking expiration dates and removing expired medications from the carts. The staff acknowledged that expired medications could be less effective or potentially cause adverse effects. A review of the facility's Medication Administration policy indicated that medications are to be administered by licensed nurses in accordance with professional standards, including identifying and notifying the nurse manager of expired medications. Despite this policy, expired medications were not removed from the medication cart as required, resulting in noncompliance with storage and labeling standards for drugs and biologicals.
Deficient Pest Control Measures Result in Roach Sightings
Penalty
Summary
The facility failed to maintain effective pest control, as evidenced by the presence of a live roach observed in the hallway of the 400 hall. Staff responses included an LVN stepping on the roach and housekeeping staff cleaning it up. Interviews with staff members, including a CNA, LVN, Maintenance Director, Environmental Supervisor, and Administrator, revealed that while pest control services are provided monthly and a pest control sighting logbook is maintained at the nurse's station, sightings of roaches have occurred and are documented. The logbook showed entries for roach sightings in April and May, and pest control invoices confirmed that treatments were performed in response to these reports. Despite these measures, the facility did not have a formal pest control policy in place, as stated by the Administrator. Staff described a process for reporting and addressing pest sightings, including deep cleaning and communication with pest control vendors, but the continued presence of roaches indicated that these actions were not fully effective in preventing pest activity within the facility. The deficiency was identified through direct observation, staff interviews, and review of pest control documentation.
Failure to Report Alleged Abuse During Bed Bath
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident during a bed bath, which was conducted by two CNAs. The incident was initially reported by a hospice CNA who observed the facility CNAs taking over the bed bath in a harsh manner, with one CNA holding the resident's hands while the other poured water over her head. The resident was reportedly upset by this treatment, and the hospice CNA intervened to complete the bath herself. The incident occurred on March 10, but was not reported to the facility's administration until March 12. The resident involved in the incident is an elderly female with severe cognitive impairment, as indicated by a BIMS score of 07. Her medical history includes dementia, chronic kidney disease, atherosclerotic heart disease, hypertension, and she is receiving palliative care. The resident has a care plan addressing episodes of smearing feces, which includes interventions such as behavioral health consults and routine incontinent care. Despite the hospice CNA's report, the facility's administrator did not report the allegation to the State Survey Agency, as they conducted an internal investigation and found no substantiated evidence of abuse. The facility's policy requires reporting of all alleged violations within specified timeframes, but this was not adhered to in this case. Interviews with the involved CNAs and the resident did not yield any direct allegations of abuse, and the facility's administrator believed the investigation was sufficient to dismiss the need for external reporting.
Inadequate Use of PPE in Contact Precaution Room
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA E, who did not don the appropriate personal protective equipment (PPE) before entering the room of a resident on contact precautions. The resident, a cognitively intact male with a history of heart failure, type 2 diabetes mellitus, and an ESBL infection in the urine, was on contact isolation due to the ESBL infection. Despite the signage indicating contact precautions, CNA E entered the resident's room without wearing a gown or gloves, moved the resident in his wheelchair, and adjusted the bedside table without using the required PPE. Interviews with various staff members, including CNA E, LVN F, CNA G, LVN ADON H, and the DON, revealed a lack of consistent understanding and adherence to the facility's infection control policies. CNA E incorrectly believed that PPE was not necessary without direct contact with the resident, while other staff members confirmed that PPE should be worn every time when entering a room with contact precautions. The facility's policy, aligned with CDC guidelines, mandates the use of PPE to prevent the transmission of infections, but the failure to adhere to these protocols was evident in this incident.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that physicians acted upon and documented their rationale in response to pharmacist recommendations for three residents. For Resident #35, the physician did not provide a rationale for the continued use of Lorazepam, Hydroxyzine, and Clonazepam until after surveyor intervention. The pharmacist had recommended a gradual dose reduction for these medications, but the physician's response was delayed and only provided after the surveyor's involvement. Additionally, the physician's rationale for extending the PRN order for Lorazepam was not documented in a timely manner. For Resident #58, the physician did not respond promptly to the pharmacist's recommendation to evaluate the continued use of Omeprazole. The pharmacist had noted that long-term use of Omeprazole could lead to increased risks of C. Diff Colitis, CAP, and B12 deficiency. The physician eventually responded by discontinuing Omeprazole and prescribing Famotidine, but this response was delayed and only occurred after the surveyor's intervention. For Resident #87, the physician did not address the pharmacist's recommendation to review the continued use of Lithium and Zyprexa. The pharmacist had recommended evaluating these medications due to their potential side effects and the need for gradual dose reduction. The facility staff failed to obtain a timely response from the physician, and the pharmacist's recommendations remained unaddressed until after the surveyor's involvement. Interviews with facility staff revealed that the responsibility for obtaining physician responses was not clearly managed, leading to delays in addressing the pharmacist's recommendations.
Expired Emergency Water Supply
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards or food service safety. During an observation of the kitchen, 27 gallons of water with a use-by date that had already passed were found stored in the emergency water supply area. The Dietary Manager, who was newly hired, acknowledged the presence of the expired water and stated that it had been there before her tenure. The Administrator also confirmed the issue and indicated that the expired water would be replaced. The facility's Emergency and Disaster Planning policy mandates that emergency water supplies must be stored under sanitary conditions and not be expired, which was not adhered to in this instance.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner documented that it was appropriate for the PRN order to be extended beyond 14 days. This deficiency was identified for one resident, a female with multiple diagnoses including convulsions, functional quadriplegia, delusion disorders, tremors, anxiety, diabetes, and major depressive disorder, who was under hospice care. The resident had an order for Lorazepam 0.5mg PRN for anxiety, which was administered multiple times over January and February without a stop date or physician evaluation for continued treatment beyond 14 days. The pharmacist consultant recommended compliance with the CMS Mega Rule Phase II, but the facility did not act on this recommendation in a timely manner, leading to the continued administration of the medication without proper documentation or evaluation by the physician. Interviews with facility staff revealed a lack of clarity and follow-through on the pharmacy consultant's recommendations, resulting in the failure to obtain a timely response from the prescribing physician. The facility's policy on psychotropic medication requires that such drugs are only given when necessary to treat a specific condition, with PRN orders limited to 14 days unless extended by a documented physician's rationale. Despite this policy, the facility did not adhere to these guidelines for the resident in question. The ADON and other staff members acknowledged the oversight and the potential adverse effects of not addressing the pharmacy consultant's recommendations promptly. The deficiency highlights a gap in the facility's process for managing PRN psychotropic medications and ensuring compliance with regulatory requirements.
Failure to Ensure Complete DNR Forms
Penalty
Summary
The facility failed to ensure that residents' Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) forms were fully and correctly completed, specifically lacking physician signatures. This deficiency was identified for two residents, one with chronic obstructive pulmonary disease, diabetes, and hypertension, and another with cerebral infarction, quadriplegia, atrial fibrillation, hypertension, and gastrostomy status. Both residents had documented DNR statuses in their care plans and medical records, but their OOH-DNR forms were missing the required physician signatures. Interviews with facility staff revealed that the social worker was responsible for obtaining the DNR forms and ensuring they were signed by the resident or their representative and witnesses. However, there was a lack of clarity and consistency in the process for obtaining the physician's signature. Staff members indicated that they considered the DNR forms valid as long as they were signed by the resident or their representative and witnesses, even if the physician's signature was missing. This practice was contrary to the requirement that a physician's signature is necessary for the DNR form to be valid. Further interviews highlighted that the facility did not have a specific policy concerning DNR forms, and there was confusion among staff about the correct procedure to follow when a resident coded. Some staff members believed that the DNR status should be honored based on the signatures of the resident or their representative and witnesses alone, while others understood that the physician's signature was also required. This inconsistency in understanding and practice could lead to residents' code status wishes not being honored in critical situations.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving Resident #49 within the required 24-hour timeframe to the State Survey Agency. Resident #49, an elderly female with Alzheimer's disease, dementia, and other mental health conditions, was observed by staff to have her breast area touched by Resident #1 while they were both in their wheelchairs. Despite the incident being observed and Resident #1 being moved to another hall, the facility did not report the incident immediately as no allegations were made at the time. It was only after Resident #49's responsible party (RP) requested the incident be reported to authorities the following day that the local police department was notified, and the incident was reported to the State Survey Agency later that evening. The investigation findings were unconfirmed for abuse, but the delay in reporting was a clear violation of the facility's policy and regulatory requirements. The Administrator acknowledged familiarity with the reporting timeline but could not explain the delay in reporting the incident. The facility's policy mandates immediate reporting of abuse allegations within two hours if serious injury is involved, or within 24 hours if not. The failure to adhere to this policy could place residents at increased risk for potential abuse and neglect due to unreported allegations.
Failure to Implement Baseline Care Plan for Feeding Assistance
Penalty
Summary
The facility failed to implement a baseline care plan for Resident #268 that included necessary instructions for feeding assistance upon her admission. Resident #268, a [AGE] year-old female with severe protein-calorie malnutrition, kyphosis, and adult failure to thrive, was admitted with hospital orders indicating she required maximum assistance for eating. However, the baseline care plan only noted that she needed setup or clean-up assistance for eating, which was insufficient given her condition. Observations revealed that Resident #268 was unable to feed herself and was not provided with the necessary assistance, leading to her being left hungry and thirsty on multiple occasions. Upon admission, the charge nurse assessed Resident #268 and observed her attempting to eat on her own, leading to the incorrect assumption that she only required supervision. This information was verbally communicated to the CNAs, who then failed to provide the necessary feeding assistance. Subsequent observations and interviews with staff indicated that Resident #268 was left without adequate support for eating, despite her evident inability to feed herself due to her physical and cognitive limitations. The occupational therapy evaluation conducted later confirmed that Resident #268 was totally dependent on assistance for all activities of daily living, including eating. Interviews with various staff members, including the Rehab Director and occupational therapist, highlighted a lack of communication and proper documentation regarding Resident #268's needs. The facility's policy required the development of a baseline care plan that included dietary orders and necessary assistance with activities of daily living, but this was not effectively implemented. The failure to address Resident #268's feeding assistance needs in her baseline care plan resulted in her not receiving the care and services required for her health and well-being.
Failure to Assist Resident with Eating
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition. Resident #268, a [AGE] year-old female with severe protein-calorie malnutrition, kyphosis, and adult failure to thrive, was admitted with hospital orders indicating she required maximum assistance for eating. Despite these orders, the facility's baseline care plan only noted set-up or clean-up assistance for eating. Observations and interviews revealed that Resident #268 was not provided with the required assistance during meals, leading to poor nutritional intake and potential weight loss. On multiple occasions, Resident #268 was observed without assistance during meal times. On 03/12/24, she was seen sitting with her food plate in front of her but not eating, and no CNA was assisting her. Later, a CNA was observed removing her meal tray, which was untouched, and incorrectly stated that the resident only required supervision. The resident herself reported being hungry and thirsty and stated that no one had assisted her with eating. Further observations showed that staff did not respond to her requests for water, indicating a lack of proper care and attention to her needs. Interviews with facility staff revealed inconsistencies in the understanding and communication of Resident #268's care needs. The charge nurse and CNA's failed to follow hospital recommendations and did not report the resident's poor meal intake to the appropriate personnel. The dietary manager's records showed fluctuating meal intake percentages, with significant instances of low intake. The Assistant Director of Nursing acknowledged that the CNA should have assisted the resident with her meals, highlighting a failure in staff training and communication regarding the resident's care requirements.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice. For Resident #36, the facility did not administer oxygen at the physician-ordered rate of 5.0 Lpm via trach mask. Observations revealed that the oxygen was set at 4.5 Lpm on multiple occasions. Additionally, the suctioning equipment for Resident #36 was not set up or connected at the bedside, which is necessary for emergency use. Interviews with staff confirmed these discrepancies and highlighted a lack of adherence to the physician's orders and facility protocols for respiratory care. For Resident #57, the facility failed to monitor and document oxygen saturation levels in percentage as ordered by the physician. The resident's records showed that oxygen saturation levels were not consistently documented in percentage form, and instead, check marks were used. This lack of proper documentation could lead to unrecognized drops in oxygen saturation levels. Interviews with staff confirmed that oxygen saturation should be documented in percentage to ensure accurate monitoring. Both residents had significant medical histories that required diligent respiratory care. Resident #36 had multiple severe conditions, including respiratory failure with hypoxia and a tracheostomy, while Resident #57 had chronic obstructive pulmonary disease and other serious health issues. The facility's failure to follow physician orders and properly document care placed these residents at risk of respiratory complications and decreased quality of care.
Failure to Store Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in locked compartments for one of eight residents reviewed for medication storage. Resident #50 was observed with a tube of Gelmicin medication on his overbed table, which he used for itching on his arms and legs. The medication was brought in by a family member from Mexico and was not prescribed by the resident's physician. The resident's care plans did not reflect any evidence that he was allowed to self-medicate, and there were no physician orders permitting self-administration of medications. Interviews with staff revealed that they were aware of the resident's use of the Gelmicin medication but had not reported it to the charge nurse or documented it in the resident's clinical chart. The Licensed Vocational Nurse (LVN) had spoken to the family member multiple times about the issue and had attempted to remove the medication from the resident's possession, but the family member continued to bring it back. The LVN had also contacted the resident's physician to prescribe an alternative medication for the itching but had not received a response until later. Further interviews with the Assistant Director of Nursing (ADON) and other staff members confirmed that residents were not allowed to keep their own medications unless permitted by a doctor's order. The staff had not documented the incident or informed the Director of Nursing (DON). The facility's policy on medication administration stated that residents are allowed to self-administer medications only when specifically authorized by the attending physician, which was not the case for Resident #50.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident who had family members bring in medications for personal use. The resident, who had moderately cognitive impairment and various medical conditions including cirrhosis of the liver and diabetes, was observed with a tube of Gelmicin medication on his overbed table. This medication was not documented in the resident's clinical chart, and there was no physician's order allowing the resident to self-administer it. Interviews with the resident and staff revealed that the family had been bringing in the medication from Mexico, and the staff were aware but had not documented this information or taken appropriate action to address it. The resident's care plans did not indicate that he would self-medicate, and there were no physician orders for self-administration of medications. Despite being aware of the situation, the staff, including a CNA and an LVN, did not report the incident to the charge nurse or document it in the resident's clinical records. The LVN had spoken to the family and the resident's physician about obtaining a similar medication but had not documented these communications. The facility's policy required accurate and timely documentation of all assessments, observations, and services provided, which was not followed in this case. Interviews with additional staff, including the ADON and RN, confirmed that residents were not allowed to keep personal medications without a doctor's order and that the staff should have documented the incident and informed the DON. The failure to document and address the resident's use of personal medication placed the resident at risk and was not in compliance with the facility's documentation policy.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
