West Rest Haven
Inspection history, citations, penalties and survey trends for this long-term care facility in West, Texas.
- Location
- 503 Meadow Drive, West, Texas 76691
- CMS Provider Number
- 676386
- Inspections on file
- 29
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 19 (3 serious)
Citation history
Health deficiencies cited at West Rest Haven during CMS and state inspections, most recent first.
A resident with metabolic encephalopathy, PVD, AKI, diabetes, and a history of multiple prior falls was care-planned as needing set-up/touching assistance for transfers and identified as a moderate fall risk, with interventions such as nonskid socks, adequate lighting, and a bedside fall mat if allowed. Despite this, the resident, who often attempted to do things independently and disliked the fall mat due to wheelchair mobility issues, experienced an unwitnessed fall from bed, was found on the floor near the doorway with blood noted by the bed and on the remote, and was later diagnosed with a head laceration requiring staples and a trace subarachnoid hemorrhage. Staff reported rounding practices and a fall prevention policy that included routine checks and use of floor mats when appropriate, but the resident’s repeated falls and this unwitnessed fall with serious head injury demonstrated that the environment and supervision were not adequate to prevent the accident.
A resident with dementia and mobility deficits, care planned for two-person mechanical lift transfers, was improperly transferred by a CNA using a gait belt and without a second staff member, resulting in a femur fracture. The CNA did not review the assignment sheet indicating the required assistance level, and staff interviews confirmed the resident's need for mechanical lift transfers with two staff at all times.
A registered nurse administered an antibiotic injection to a resident without obtaining a physician's order, acting outside her scope of practice and against facility policy. The resident had a history of UTIs and moderate cognitive impairment, and lab results indicated a possible infection, but further testing was pending. The nurse assumed the medication would be appropriate and documented the administration without physician authorization. The incident was identified when the DON reviewed the order and confirmed with the medical director that no order had been given.
A registered nurse administered an antibiotic injection to a resident without obtaining a physician's order, despite facility policy requiring such authorization. The resident, who had moderate cognitive impairment and a history of UTIs, received the medication based solely on the nurse's judgment after lab results suggested a possible infection.
Multiple residents did not have individualized, comprehensive care plans addressing their specific medical, nursing, and psychosocial needs, including lack of clear transfer instructions, contracture management, PTSD interventions, and infection management. Staff often failed to use required assistive devices or document care, and care plans were not updated to reflect residents' current conditions, as confirmed by observations, interviews, and record reviews.
Several residents did not receive proper supervision or use of assistive devices during transfers, resulting in one resident sustaining multiple fractures and a scalp laceration after a fall, and others experiencing bruising or unsafe transfer practices. Staff failed to consistently use gait belts and did not address hazards such as missing protective caps on equipment, despite care plans and facility policies requiring these safety measures.
Several residents with various psychiatric and neurological diagnoses were administered psychotropic medications, including antipsychotics, antidepressants, and antianxiety agents, without documented informed consent. Despite care plans indicating the need for education on medication risks and benefits, required consents were not found in the medical records. Nursing staff and the DON confirmed that the process for obtaining and filing consents was not consistently followed, resulting in medications being given without proper authorization.
Surveyors found multiple deficiencies in medication labeling and storage, including an undated and unlabeled bottle of Systane eye drops, loose unidentified pills in several medication carts, and an expired bottle of magnesium oxide. Staff interviews confirmed that these practices did not align with facility policy or professional standards.
A resident with multiple chronic conditions reported her hearing aids missing to a social worker and an LVN, but neither initiated the required grievance process or documented the complaint. Staff interviews revealed confusion about grievance procedures, and the facility's grievance log showed no record of the incident, despite policy requiring prompt reporting and written documentation of grievances.
A resident with multiple health conditions and requiring substantial assistance with transfers suffered a witnessed fall resulting in serious injuries while being assisted by a CNA who did not use a gait belt or provide hands-on support. The incident was not reported to the State Agency within the required timeframe, and staff did not initially recognize the event as potential neglect. The facility did not obtain hospital records promptly or restrict the CNA from resident care immediately after the incident.
A resident with dementia and Alzheimer's disease expired in the facility, but the required discharge MDS assessment was not completed or transmitted within the mandated timeframe. The last MDS submitted was the admission assessment, and the discharge assessment was found to be significantly overdue, with staff interviews confirming the lapse was due to the absence of an MDS coordinator.
A resident's MDS assessment inaccurately indicated no dental issues, despite documentation and observation of broken natural teeth. The resident's care plan and psychosocial notes reflected her refusal of dental care, and staff confirmed ongoing oral care. The discrepancy between the MDS and actual oral status was identified through record review, interviews, and observation.
A resident with documented diagnoses of psychotic disorder, major depressive disorder, and anxiety disorder was admitted without these mental illnesses being accurately reflected on the PASRR Level 1 Screening. The screening form was incorrectly marked as negative for mental illness, despite medical records and care plans indicating otherwise. Facility leadership acknowledged the error and the expectation for accurate and timely PASRR completion.
A resident with multiple diagnoses and memory impairment required extensive assistance and a mechanical lift for transfers, but the care plan was not updated to reflect these needs. Documentation and staff interviews confirmed the resident's increased dependence, yet the care plan continued to indicate only limited assistance was necessary, contrary to facility policy requiring timely care plan revisions by the IDT.
A resident with hemiplegia and a left-hand contracture did not receive appropriate contracture management, as her care plan lacked specific interventions, therapy devices were not used, and staff were unclear about responsibility for ongoing care. The resident was not receiving restorative services or documented contracture management, and her hand hygiene needs were not consistently addressed.
A resident with PTSD did not have specific trauma triggers identified in her care plan, despite staff awareness of her diagnosis and the importance of such information. The care plan included only general interventions, and staff interviews confirmed that no trauma assessment or trigger identification had been completed or documented.
A resident with a history of UTIs and moderate cognitive impairment was given Keflex as a prophylactic antibiotic without adequate indication or care plan documentation. Staff interviews revealed that antibiotic use was not properly monitored or reviewed, and facility policies for infection surveillance and antibiotic stewardship were not followed in practice.
The facility did not maintain proper temperature logs or ensure safe refrigeration in one nourishment room, and failed to label and date food items in another. Staff interviews revealed unclear responsibilities for monitoring and reporting, and the facility's policy requiring labeling of outside food was not consistently followed.
A resident received prophylactic antibiotics without written justification or proper care plan documentation, and the facility did not use established criteria to determine the need for antibiotic therapy. Staff interviews revealed a lack of symptom tracking and inconsistent pharmacy review of antibiotic use, despite facility policies requiring standardized assessment and oversight.
Failure to Prevent Fall and Head Injury in Known Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s environment free from accident hazards and to provide adequate supervision and fall interventions, resulting in a fall with head laceration and a trace subarachnoid hemorrhage. The resident was an adult male with diagnoses including metabolic encephalopathy, peripheral vascular disease, acute kidney injury, and diabetes. His most recent MDS showed a BIMS score of 14, indicating he was cognitively intact, with no functional limitation in lower extremity range of motion, and he required only set-up or clean-up assistance for transfers and sit-to-stand. His care plan identified an ADL self-care performance deficit related to mild cognitive impairment and metabolic encephalopathy, and documented that he required set-up to touching assistance with transfers by one staff member. The resident had a documented history of multiple prior falls, including falls while attempting to self-transfer, falls in his room and restroom, and a fall with a head laceration that led to transfer to the hospital. His care plan for actual falls related to unsteady gait listed multiple fall events with dates and noted that he had a goal to resume usual activities without further incident. Interventions on the care plan included encouraging the resident to wear nonskid socks, ensuring adequate lighting, and using a fall mat at bedside if the resident allowed. Physician orders also included floor mats at bedside if the resident allowed, and a Morse Fall Scale assessment identified him as at moderate risk for falls. On the day of the incident, the resident reported that he believed he had been asleep and fell out of bed, striking his head and causing bleeding, but he could not recall what he was doing before the fall or how it occurred. Staff interviews indicated that the CNA assigned to the hall was making rounds room to room and had been in the room next door to the resident when she saw what she initially thought were socks on the floor, then realized it was the resident’s feet. She found the resident on the floor near the doorway, alert and responsive, with blood noted by the bed. The LVN reported she had not been down the hall for about 30 minutes but knew the CNA was rounding; when called, she assessed the resident, noted a bleeding head wound, and observed blood on the remote hanging off the bed and on the floor by the head of the bed. The resident was later diagnosed at the hospital with a laceration to the back of the head requiring 12 staples and a trace subarachnoid hemorrhage of the anterior interhemispheric fissure. The facility’s fall prevention policy required evaluation of fall risk, routine visits to check on residents, use of bedside floor mats when appropriate, and documentation of interventions, but the resident’s repeated falls and the circumstances of this unwitnessed fall demonstrated that the environment and supervision were not sufficient to prevent this accident. The resident expressed that he did not like the fall mat by his bed because it made wheelchair mobility more difficult, and family and staff interviews confirmed he frequently attempted to do things on his own and did not consistently use the call light. The DON and ADM stated that staff were expected to round on residents at least every two hours, with some staff reporting they rounded more frequently, such as every 30 minutes to an hour. Despite these stated practices and the resident’s known fall history and moderate fall risk, the fall occurred unwitnessed between staff checks, with the resident found on the floor by the door and evidence of blood near the bed and on the remote. The combination of the resident’s established fall risk, prior falls while self-transferring, care-planned need for assistance with transfers, and the unwitnessed nature of the fall with serious head injury formed the basis for the cited deficiency in providing an environment free from accident hazards and adequate supervision to prevent accidents.
Failure to Provide Required Two-Person Mechanical Lift Transfer Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with significant cognitive and physical impairments was not provided the required level of assistance during a transfer. The resident, who had diagnoses including dementia, muscle weakness, abnormal gait, and a history of femur fracture, was care planned to require a mechanical lift with two staff for all transfers. Despite this, a CNA transferred the resident from bed to wheelchair by holding onto the resident's pants and using a gait belt, without the assistance of a second staff member or the mechanical lift as required. The CNA did not consult the assignment sheet at the start of her shift, which would have indicated the resident's transfer needs. Interviews with facility staff, including the DON, RN, LVN, and multiple CNAs, confirmed that the expectation and policy were for the resident to be transferred with a mechanical lift and two staff at all times. Assignment sheets detailing each resident's transfer requirements were available at each nurse's station, and staff were expected to review these at the beginning of each shift. The incident report and hospital records indicated that the resident sustained an acute, slightly displaced fracture of the left greater trochanter as a result of the improper transfer. The resident was subsequently hospitalized and returned to the facility with pain management orders. The investigation found that the CNA involved had not followed established procedures for reviewing assignment sheets or adhering to the resident's care plan. The resident's inability to recall the incident or report pain was consistent with her documented cognitive impairment. Other staff interviews confirmed knowledge of the correct transfer procedures and the location of assignment sheets, but the failure to follow these protocols in this instance led directly to the resident's injury.
RN Administers Antibiotic Without Physician Order
Penalty
Summary
A registered nurse (RN) administered an antibiotic injection to a resident without obtaining a physician's order, which is outside the RN's scope of practice and contrary to facility policy. The resident, who had a history of anxiety, unspecified psychosis, urinary tract infection (UTI), and nausea, was admitted with moderate cognitive impairment and required moderate assistance with activities of daily living. Lab results indicated a possible UTI, and further testing was pending to determine the appropriate antibiotic. Despite this, the RN ordered and administered Ceftriaxone from the emergency kit, documenting the action as a preventive measure against sepsis or worsening condition, but without physician authorization. The incident was discovered when the Director of Nursing (DON) reviewed the order and confirmed with the medical director that no order had been given for the antibiotic. The RN admitted to not contacting the physician and stated she assumed the medication would be appropriate based on the resident's history and symptoms. The facility's pharmacy policy requires that no medication be administered without a written physician's order. The medical director confirmed he was not contacted and did not authorize the medication. The resident did not experience any negative outcomes as a result of the unauthorized administration.
Medication Administered Without Physician Order
Penalty
Summary
A registered nurse (RN) administered Ceftriaxone, an antibiotic, intramuscularly to a resident without obtaining a physician's order. The resident had been admitted with diagnoses including anxiety, unspecified psychosis, urinary tract infection (UTI), and nausea. Laboratory results indicated a possible UTI, but further testing was required to determine the appropriate antibiotic. Despite this, the RN wrote and signed an order for Ceftriaxone and administered the medication from the emergency kit, without consulting or receiving authorization from the resident's physician. The medication administration record and nursing progress notes confirmed that the RN acted independently, and the physician later confirmed that no order had been given for the antibiotic. The resident in question had moderate cognitive impairment and required moderate assistance with activities of daily living. The incident was discovered when the Director of Nursing (DON) reviewed the order and found discrepancies, leading to confirmation that the physician had not been contacted. The facility's policy clearly states that no medication should be administered without a written physician's order. The RN admitted to administering the medication based on her own judgment, citing the resident's previous history with Ceftriaxone and the timing of the lab results.
Failure to Develop and Implement Comprehensive, Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, as required by regulation. Specifically, care plans did not include individualized, measurable objectives and timeframes to address residents' medical, nursing, and psychosocial needs identified in their assessments. For several residents, care plans lacked specific instructions regarding transfer methods, such as the use of gait belts, mechanical lifts, or stand aids, despite documented needs for substantial or maximal assistance. Observations and interviews revealed that staff often did not use gait belts during transfers, and care plans did not specify the required level of assistance, leading to unsafe transfer practices. In one instance, a resident fell and sustained a laceration during a transfer when staff failed to provide hands-on assistance or use a gait belt, as required by her condition and facility expectations. Another resident with a left-hand contracture did not have a comprehensive care plan addressing contracture management, despite observable limitations and the presence of therapy devices in her room. Interviews with staff and therapy personnel indicated that there was no written plan or documentation for the use of contracture management devices, and restorative care for the contracture had been discontinued without a formal plan or communication to nursing staff. The resident reported that staff rarely assisted with her contracture devices or nail care, and observations confirmed the lack of consistent intervention. Additionally, a resident with a diagnosis of PTSD did not have a care plan that identified her specific triggers or individualized interventions, despite her mental health history and the facility's process for collecting trauma histories. The social worker responsible for trauma-related care plans was unaware of the resident's PTSD diagnosis and had not documented any triggers or interventions. Another resident with recurrent UTIs and prophylactic antibiotic use did not have a care plan addressing infection management or monitoring for side effects, even though she had multiple documented infections and ongoing antibiotic therapy. These deficiencies were identified through observation, interview, and record review, and were confirmed by facility leadership.
Failure to Provide Adequate Supervision and Assistive Devices During Resident Transfers
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents, as evidenced by multiple incidents involving four residents. One resident, who had a history of fractures, repeated falls, osteoporosis, and mild cognitive impairment, required substantial to maximal assistance for transfers according to her care plan and therapy evaluation. However, during a sit-to-stand transfer, the assigned CNA did not provide contact guard assistance or use a gait belt, instead standing by and holding the wheelchair while the resident attempted to transfer herself. This resulted in the resident falling headfirst into a wall, causing multiple rib fractures, a cervical vertebra fracture, a compression fracture, and a scalp laceration. Other residents also experienced deficiencies in supervision and use of assistive devices. One resident, with a history of osteoporosis, muscle weakness, and falls, reported bruising on her arm from contact with an exposed metal nut on the stand aid device, which was missing its protective plastic cap. Staff interviews revealed that the issue had been verbally reported to a nurse, but no maintenance request had been made, and maintenance staff were not routinely checking for missing caps. Another resident, who was hemiplegic and at high risk for falls, reported that staff often did not use a gait belt during transfers and sometimes pulled on his clothing instead. Observations confirmed that staff did not always use gait belts as required by policy and care plans. Additionally, a resident with arthritis, cataracts, and legal blindness was observed being transferred with a stand aid without a gait belt and while wearing non-slip-resistant socks. The CNA involved admitted to forgetting the gait belt and recognized the risk of falls without proper equipment. Review of facility policies indicated that staff were expected to use gait belts and follow individualized care plans for transfers, but these protocols were not consistently followed, leading to actual harm and the identification of Immediate Jeopardy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration of psychotropic medications for multiple residents. For one resident with diagnoses including acute respiratory failure, PTSD, schizoaffective disorder, and low back pain, there was no signed consent for Depakote Sprinkles, despite the medication being administered as ordered. The resident had moderately impaired cognition and was receiving several psychotropic medications, but neither the electronic nor paper medical records contained the required consent documentation. Another resident with unspecified dementia, depression, anxiety disorder, and psychosis, and who had severely impaired cognition, was administered Seroquel without a signed consent. The medication was given as ordered except for a few refusals, but no documentation of informed consent was found in the records. Similarly, a third resident with anxiety disorder, dementia, and mood disorder, and who also had severely impaired cognition, was administered Sertraline and Seroquel without any signed consents present in the medical records. A fourth resident, who was cognitively intact and had diagnoses including psychotic disorder with delusions, hemiplegia, and hemiparesis, was administered Duloxetine, Depakote, Xanax, and Risperdal without signed consents. The care plans for these residents included interventions to educate about risks, benefits, and side effects, but the required consents were not obtained or documented. Interviews with nursing staff and the DON confirmed that the process for obtaining and filing consents was not consistently followed, and that the lack of consents could result in residents receiving medications that they or their families did not want.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices across four medication carts. An undated and unlabeled bottle of Systane eye drops was found in the Station 1 south-hall medication cart, with no resident name or label to identify ownership. Additionally, three loose, unidentified pills were found in the Station 1 east-hall medication cart, one loose pill in the Station 2 south-hall cart, and eighteen loose, unidentified pills in the Station 2 north-hall cart. An expired bottle of magnesium oxide, labeled with a best by date of 02/2025, was also found in the Station 2 north-hall cart. Staff interviews confirmed that nurses were responsible for maintaining the order and cleanliness of the medication carts, and that medications should be dated when opened and stored in their original containers. Despite these expectations, the observations revealed that medication carts were not consistently maintained according to facility policy and professional standards. Staff members acknowledged that loose pills should not be present in the carts and that dropped pills should be removed immediately. The Director of Nursing and Assistant Administrator both stated that the findings did not meet their expectations for medication storage. Review of the facility's procedure for medication storage confirmed that drugs should be stored in an orderly manner and in their originally received containers, which was not followed in these instances.
Failure to Initiate and Document Grievance Process for Lost Hearing Aids
Penalty
Summary
The facility failed to ensure that a resident's right to voice grievances was honored and that prompt efforts were made to resolve those grievances. Specifically, a resident with a history of diabetes, chronic kidney disease, uterine cancer, major depressive disorder, hypertension, and heart failure reported the loss of her hearing aids, which were routinely collected by nursing staff for charging. The resident communicated the loss to the social worker (SW), who acknowledged being told about the missing hearing aids but did not initiate the facility's grievance process as required by policy. The SW attempted to find a replacement provider but did not document or formally report the grievance. Additionally, a Licensed Vocational Nurse (LVN) was made aware of the missing hearing aids but did not initiate the grievance process or report the issue to her supervisor until prompted by the surveyor. The LVN supervisor and assistant administrator both confirmed that they were not informed of the missing hearing aids until much later, and the facility's grievance log showed no record of a grievance being filed for this incident. Interviews revealed that staff were unclear about the proper procedures for reporting and documenting grievances, despite the facility's policy requiring any employee to report grievances to their department head or charge nurse and for a written report to be initiated. The facility's grievance policy states that residents or their representatives have the right to file grievances orally or in writing and expect a written decision within seven working days. However, in this case, the process was not followed, and the resident's concern about her missing hearing aids was not formally addressed through the established grievance system. This failure was identified through interviews and record reviews, which showed a lack of documentation and appropriate response to the resident's complaint.
Failure to Timely Report Serious Resident Injury Following Fall
Penalty
Summary
The facility failed to immediately report an incident involving a resident who experienced a witnessed fall resulting in multiple serious injuries, including rib fractures, a cervical spine fracture, a thoracic compression fracture, and a scalp laceration. The fall occurred while the resident, who had a history of heart failure, osteoporosis, depression, mild cognitive impairment, and required substantial to maximal assistance with transfers, was being assisted by a CNA. The CNA did not use a gait belt and was not physically assisting the resident during the transfer, contrary to the resident's care plan and functional assessment, which indicated the need for moderate assistance. Following the fall, the resident was transported to the hospital, where her injuries were confirmed. Despite the severity of the injuries and the witnessed nature of the fall, the facility did not report the incident to the State Agency within the required two-hour timeframe. The DON and nurse supervisor did not initially recognize the incident as potential neglect or abuse, and the extent of the resident's injuries was not known to the facility until hospital records were received upon the resident's re-admittance. The facility's investigation did not include obtaining hospital records at the time of the incident, and the CNA involved was not suspended or restricted from resident care immediately following the event. Interviews with staff revealed a lack of clarity regarding reporting requirements and the appropriate response to such incidents. The nurse supervisor viewed the event as a failure in transfer technique rather than a potential case of neglect, and the DON was unaware of the need to report the injuries to the State Agency. The facility's policies required immediate reporting of suspected abuse, neglect, or misappropriation of resident property, but these procedures were not followed in this case.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for a resident who expired in the facility. The resident, an elderly female with dementia and Alzheimer's disease, was admitted and later transitioned to palliative care before passing away. Review of her records showed that her last transmitted MDS was the admission assessment, and the required discharge MDS was not completed or submitted within the mandated timeframe. The MDS transmission system indicated that the discharge assessment was 141 days overdue. Interviews with facility staff revealed that the absence of an MDS coordinator contributed to the missed assessment. The Director of Nursing acknowledged responsibility for the oversight and confirmed that the discharge MDS should have been completed and transmitted. The facility's policy and the RAI Manual require timely completion and submission of MDS assessments, including discharge assessments, but these procedures were not followed in this instance.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected her oral and dental status. Specifically, the MDS assessment indicated that the resident had no dental issues, as the box for 'None of the above were present' was checked in Section L - Oral/Dental Status. However, record review and interviews revealed that the resident had broken natural teeth, which was documented in a psychosocial note and observed during an interview. The resident herself acknowledged having broken teeth, though she stated they did not cause her pain and she did not wish to have them fixed. Further review showed that the resident's care plan noted her refusal of dental care, and staff interviews confirmed that oral care was being provided and any changes were reported to nursing staff. The Director of Nursing acknowledged that the MDS should be coded as accurately as possible and that inaccuracies could affect the overall assessment and care provided. The facility's policy requires resident information to be as accurate and truthful as possible, but this was not followed in the case of the resident's dental status.
Inaccurate PASRR Level 1 Screening for Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I assessment for one resident. The PASRR Level I Screening, completed prior to admission, did not indicate a diagnosis of mental illness, despite the resident having documented diagnoses of psychotic disorder with hallucinations, major depressive disorder, and anxiety disorder upon admission. The resident's face sheet and quarterly MDS assessment confirmed these mental health diagnoses, and the care plan included interventions for major depressive disorder. However, the PASRR Level I Screening form incorrectly reflected that the resident did not have a primary diagnosis of mental illness. Interviews with the DON revealed that the PASRR screening should have been positive due to the resident's mental illness diagnosis, but was incorrectly marked negative. The DON acknowledged responsibility for PASRRs and stated that a corrected screening should have been completed and sent to the local authority for evaluation. The facility's PASRR policy was requested but not provided prior to the survey exit. The Assistant Administrator also confirmed the expectation that PASRR Level 1 Screenings are completed accurately upon admission and corrected immediately if errors are found.
Failure to Update Care Plan for Resident Requiring Extensive Transfer Assistance
Penalty
Summary
The facility failed to review and revise the comprehensive, person-centered care plan for one resident who required assistance with transfers. Despite documentation and staff interviews indicating that the resident had progressed to needing extensive assistance and the use of a mechanical lift for transfers, the care plan continued to state that only limited assistance by one staff member was required. Observations confirmed the resident was using a mechanical lift with a blue sling and required two staff for transfers, as corroborated by a CNA who reported that the resident had not used the Stand Aid for several weeks. The resident's medical record reflected multiple diagnoses, including muscle weakness, difficulty walking, and unsteadiness, and the most recent MDS assessment showed memory impairment and a need for partial to moderate assistance with transfers. However, transfer documentation over a one-month period showed the resident required extensive assistance or was totally dependent for most transfers. The facility's policy required care plans to be updated by an interdisciplinary team after each assessment, but this was not done in this case, resulting in an inaccurate care plan that did not reflect the resident's current needs.
Failure to Provide Contracture Management for Resident with Limited ROM
Penalty
Summary
A resident with a history of hemiplegia and hemiparesis was admitted with functional limitations in range of motion (ROM) on one side, specifically affecting her left upper extremity. The resident's care plan noted contractures of the left upper extremity and included interventions for skin care, but did not address specific management for her left-hand contracture. There were no physician orders or occupational therapy treatment plans targeting the left-hand contracture, and the occupational therapy evaluation did not provide a specific plan for this issue. Observations revealed the resident had a left-hand contracture with fingers fixed in a closed position and lacked any palm guard or device in place. Therapy carrots, intended for contracture management, were found unused in the resident's room. The resident reported that staff rarely assisted with her hand or trimmed her fingernails, and that the therapy devices were seldom used. Interviews with staff indicated that the resident was not currently receiving restorative care for her contracture, and there was no documentation or plan for contracture management in her medical record. Staff were unclear about responsibility for ongoing contracture care after discharge from restorative services. Further review showed that although a restorative hand program had previously been in place, it was not active at the time of the survey, and the interventions outlined in the program were not being implemented. The DON confirmed that the resident was not receiving restorative care for her contracture and that contracture management was not included in her current care plan. The administrator stated that residents with contractures should remain on restorative care or receive treatment from floor staff, and that failure to do so could result in worsening of the contracture.
Failure to Identify Trauma Triggers for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of post-traumatic stress disorder (PTSD) received trauma-informed, culturally competent care in accordance with professional standards. Record review showed that the resident's care plan acknowledged a history of trauma and included general interventions such as approaching the resident calmly and avoiding startling her. However, the care plan did not identify any specific triggers related to the resident's trauma, despite her documented PTSD diagnosis. The resident's social history and psychiatric assessments also lacked documentation of trauma triggers, and there was no evidence of a trauma assessment being completed after regulatory changes. Interviews with facility staff, including the Social Worker, DON, and Assistant Administrator, revealed that staff were aware of the importance of identifying trauma triggers but could not confirm that this had been done for the resident in question. The Social Worker stated she did not recall assessing the resident for trauma or identifying triggers, and the DON and Assistant Administrator both indicated that care plans should include specific triggers to prevent re-traumatization. A policy for trauma-informed care was requested by surveyors but was not provided before the survey exit.
Failure to Ensure Drug Regimen Free from Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically by administering Keflex as a prophylactic antibiotic without adequate indication. The resident, a female with a history of urinary tract infections (UTIs) and moderate cognitive impairment, was prescribed Keflex 500mg at bedtime for prevention, despite not having current symptoms or a documented infection at the time. The resident's care plan did not include entries related to UTIs or antibiotic use, and her medical records showed she had been diagnosed with UTIs on three separate occasions, each treated with different antibiotics based on culture results. Interviews with facility staff revealed gaps in monitoring and documentation practices. The Assistant Director of Nursing/Infection Preventionist (ADON IP) stated that the only form used for antibiotics was the infection surveillance report and that there was no other system in place to document symptoms or track infections. The Director of Nursing (DON) indicated that the family had requested ongoing antibiotics and believed the pharmacist was reviewing antibiotic use, but acknowledged the absence of a standardized form for tracking UTI symptoms. The Medical Director and Pharmacy Consultant both confirmed that prophylactic antibiotic use was not being routinely reviewed or monitored, and recommendations regarding ongoing antibiotic therapy were not being communicated to the prescribing physician. Facility policies referenced the use of McGeer Criteria for infection surveillance and outlined expectations for antibiotic stewardship, including assessment, documentation of indication, dose, and duration, and periodic review of antibiotic use. However, these protocols were not followed in practice, as evidenced by the lack of care planning, inadequate monitoring, and absence of documentation supporting the ongoing use of prophylactic antibiotics for the resident.
Deficient Food Storage and Labeling in Nourishment Room Refrigerators
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the management of nourishment room refrigerators in two stations. At station #2, the temperature log for the nourishment refrigerator was not maintained after a certain date, and the refrigerator was observed to be operating at 52 degrees, which is above the recommended temperature for safe food storage. Several nutritional shakes inside the refrigerator were noted to be only slightly cooler than room temperature. Additionally, the staff interviews revealed confusion regarding responsibilities for maintaining the temperature log and monitoring refrigerator conditions. At station #1, the refrigerator contained multiple food items that were not labeled or dated, including a container of cut watermelon, a container with an unknown substance, and a carton of almond milk. Although a sign instructed family members to label and date all food items, these instructions were not followed. Housekeeping staff reported that they were responsible for ensuring items were labeled and dated, and would report non-compliance to their supervisor, who would then inform nursing. The facility's policy required all refrigerated food or drink brought in for residents to be labeled with the resident's name, date, and product name, but this was not consistently implemented.
Failure to Ensure Appropriate Antibiotic Stewardship and Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by not ensuring the appropriate use of antibiotic therapy and not providing written rationale from the provider when an antibiotic was used outside of established criteria. For one resident, there was no documentation that established and accepted criteria, such as the McGeer or CDC criteria, were used to determine if her urinary tract infection (UTI) met the requirements for antibiotic use. Additionally, the resident was receiving a prophylactic antibiotic (Keflex) without written justification for its use, and her care plan did not include entries related to UTIs or antibiotic use. Record reviews showed that the resident had been diagnosed with UTIs on three separate occasions, with symptoms documented as altered mental status, increased confusion, and not feeling well, but without comprehensive symptom tracking or documentation of other required criteria. The infection surveillance reports did not consistently document all necessary symptoms, and the facility did not have a standardized form to track symptoms at the onset of UTI symptoms. Interviews with staff revealed that there was no system in place to track symptoms, and the only form used was the infection surveillance report. The pharmacy consultant was not reviewing residents on prophylactic antibiotics or sending recommendations to the medical director, and the pharmacist's review of antibiotics was inconsistent and did not include ongoing prophylactic use. Facility policies referenced the use of McGeer criteria and the importance of antibiotic stewardship, including assessment using standardized tools, specifying dose, duration, and indication, and periodic review of antibiotic prescriptions. However, these policies were not followed in practice, as evidenced by the lack of documentation, symptom tracking, and oversight of antibiotic use for the resident in question.
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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