Westpark Rehabilitation And Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Euless, Texas.
- Location
- 900 Westpark Way, Euless, Texas 76040
- CMS Provider Number
- 676029
- Inspections on file
- 49
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Westpark Rehabilitation And Living during CMS and state inspections, most recent first.
Surveyors found that two residents with significant cognitive and physical impairments, including dementia, Alzheimer’s disease, contractures, and fall risk, did not have accessible call lights while in bed, despite care plans and facility policy requiring call devices to be within reach. One resident reported having no way to call staff and believed she did not have a call light, which was later observed attached to the roommate’s bed. The other resident reported long waits for assistance and that her call light was often not near her; surveyors observed her call light on the floor behind a mat rather than on her bed.
A resident with quadriplegia and a physician order for nebulizer treatments did not have the use of the nebulizer included in their care plan. Despite staff awareness of the order and the resident's use of the device, the care plan was not updated to reflect this need, resulting in a lack of documented interventions and guidance for staff.
A resident with severe cognitive impairment and muscle weakness, identified as a fall risk, did not have a physician order for a scoop mattress and had a fall mat observed leaning against the wall instead of being placed next to the bed as required by the care plan. Nursing staff confirmed the interventions were not properly implemented, resulting in a failure to provide adequate accident prevention measures.
A resident with quadriplegia and a physician's order for nebulizer treatments was found to have her nebulizer mask left unbagged on a nightstand when not in use. Staff interviews confirmed that the mask should have been bagged to prevent infection, and the resident's care plan did not address nebulizer use. The facility's policy required proper respiratory care practices, which were not followed in this instance.
Surveyors found that a treatment cart was left unlocked and unattended, with all drawers and supplies accessible, while a resident in a wheelchair was nearby. The DON confirmed the cart was not secured and stated that staff are expected to keep treatment carts locked when not in use, in line with facility policy requiring all drugs and biologicals to be stored securely and accessible only to authorized personnel.
Two residents were not provided with their prescribed medications following admission, including a seizure medication and multiple inhalers for respiratory conditions. The facility did not obtain or document hospital discharge orders in a timely manner, and staff failed to administer or record the administration of these essential medications as required by policy.
A resident in an LTC facility suffered physical abuse by an LVN, resulting in fractures to her right elbow and wrist, necessitating surgery. The incident occurred during an altercation where the LVN pushed the resident, causing her to fall. The injuries were not immediately reported as abuse, and the LVN was later terminated following an investigation.
Two residents in the facility were found with inaccessible call lights, violating their right to reasonable accommodation of needs. One resident had his call light clipped to a privacy curtain, while another's was blocked by an oxygen concentrator. Both residents, who required assistance due to muscle weakness and cognitive impairments, were unable to call for help. Staff interviews confirmed the expectation for call lights to be within reach, as per facility policy.
A resident with a suprapubic catheter was found with the catheter bag and drain valve on the floor, risking infection. Staff interviews confirmed the importance of keeping the catheter bag off the floor to prevent contamination, aligning with facility policy on infection control.
A resident with COPD did not receive proper respiratory care as their nebulizer mask was left unbagged on a drawer, contrary to facility policy. The resident was not informed about the need to bag the mask, and the nurse failed to notice the oversight. Interviews with the ADON and DON confirmed the importance of bagging the mask to prevent infection.
A resident with cerebral palsy received care from staff who failed to perform proper hand hygiene and glove changes, leading to potential cross-contamination. COTA G and CNA F did not change gloves after handling soiled items, and COTA G continued using gloves contaminated with feces. The facility's policy requires hand hygiene and glove changes, which were not followed during this incident.
A resident with obstructive and reflux uropathy was not provided a privacy bag for her catheter bag, resulting in a failure to maintain her dignity. The catheter bag was observed exposed and visible, contrary to the facility's policies on dignity and catheter care. Staff, including an RN, DON, and ADON, acknowledged the oversight and the importance of using privacy bags to prevent embarrassment.
The facility failed to maintain a clean and sanitary environment in seven resident rooms and hallways, with observations of dirt, dust, and stains. Staff interviews revealed a lack of awareness and communication regarding these issues, despite the facility's cleaning policy requiring housekeeping to maintain equipment and areas as bacteria-free as possible.
The facility failed to properly store respiratory equipment for three residents, risking infection. A resident's nasal cannula was left unbagged on a stuffed rabbit, another's nebulizer mask was unbagged on a nightstand, and a third's nasal cannula was tangled and touching the floor. Staff failed to notice these issues, despite care plans requiring equipment to be bagged when not in use.
The facility's kitchen failed to meet food storage and sanitation standards, with unclean equipment and improperly labeled food items. The ice scoop and ice chest were dirty, and food in the refrigerator and freezer lacked proper date labeling. The tea dispenser was uncovered, and cooking equipment was stained. The dietary manager was on leave, and no temporary manager was designated, leading to a lack of accountability for kitchen cleanliness.
Two CNAs failed to follow infection control protocols during incontinent care for two residents, leading to potential cross-contamination. One CNA did not change gloves or perform hand hygiene after cleaning a resident's bottom, and placed a cleanser from her pocket onto a new brief. Another CNA did not sanitize hands before care and placed a new brief on soiled padding. Both CNAs admitted to not following proper procedures despite training.
A resident's call light was not answered for over an hour, highlighting a deficiency in the facility's response time to call lights. Interviews and observations revealed that staff often took 30 minutes to over an hour to respond, contrary to the facility's policy. This delay in response time was acknowledged by multiple staff members and noted in the facility's grievance log.
A resident's privacy was compromised when an LVN failed to close the door while checking blood sugar and administering insulin, leaving the resident visible from the hallway. The resident, diagnosed with type 2 diabetes and dementia, had a care plan that included closing the door to reduce distractions. Interviews with facility staff confirmed the expectation to maintain privacy during treatments.
A resident's Quarterly MDS Assessment failed to reflect her continuous use of oxygen therapy, despite her diagnosis of respiratory failure with hypoxia and a physician's order for oxygen. Staff interviews revealed a lack of awareness and oversight in the assessment process, with the MDS Nurse admitting to overlooking the resident's oxygen therapy. This discrepancy highlights a gap in the facility's adherence to its policy on accurate resident assessments.
A facility failed to obtain physician orders or conduct an assessment before using a scoop mattress for a resident with seizures and muscle weakness, potentially exposing the resident to accident hazards. The DON acknowledged the mattress was provided without proper authorization, sometimes at family request.
A facility failed to provide proper incontinent care for a resident with dementia and muscle weakness, risking urinary tract infection. A CNA reused wipes during cleaning, contrary to policy, which requires a new wipe for each stroke to prevent cross-contamination. Interviews confirmed the CNA's understanding of the error and the facility's policy on infection prevention.
A resident with severe cognitive impairment and dysphagia was not provided proper g-tube care, as a syringe used for medication administration was not replaced daily, and an abdominal binder was not applied as ordered. The LVN failed to check the syringe date, and there was no documentation of the resident refusing the binder. Interviews with the ADON and DON confirmed these lapses, which were against the facility's policy and physician's orders.
A non-verbal resident with severe cognitive impairments was sexually abused by a CNA in an LTC facility. Video evidence showed the CNA engaging in inappropriate conduct while providing care. The resident, dependent on staff for all activities, was unable to communicate the abuse. Despite staff awareness of reporting procedures, the incident occurred, revealing lapses in oversight and monitoring.
A resident with severe cognitive impairments was sexually abused by a CNA, despite the facility's policies prohibiting mistreatment and abuse. The incident was captured on video, and the resident, who was non-verbal and dependent on staff for care, was unable to communicate the abuse. The facility's investigation was ongoing, and the CNA was suspended. Staff interviews indicated awareness of abuse reporting procedures, but the incident revealed a failure in policy implementation.
The facility failed to implement a comprehensive care plan for a resident with a history of stroke, requiring two staff members for incontinence care. Despite the care plan's instructions, a CNA provided care alone, and the DON stated that the care plan was a guide, allowing for changes based on the resident's participation level.
A facility failed to maintain an infection prevention and control program when a CNA did not perform hand hygiene between glove changes and did not clean a urine-soiled mattress during incontinence care for a resident with a history of frequent UTIs. The DON confirmed the importance of these actions in preventing infection.
Failure to Keep Call Lights Accessible for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate resident needs by ensuring call lights were accessible to residents while in bed. For one resident, an older female with multiple diagnoses including cerebral infarction, type 2 diabetes, vascular dementia, Alzheimer’s disease, mood disorder, insomnia, hypertension, muscle weakness, lack of coordination, cognitive communication deficit, aphasia, and a history of adult failure to thrive, the MDS showed severe cognitive impairment and a need for assistance with activities of daily living. Her care plan identified fall risk with interventions that included keeping the call light within reach and educating her to use it for assistance, especially after an actual fall. Despite these documented needs and interventions, surveyor observation found that this resident did not have a call light within reach on her side of the room. During interview and observation, this resident stated she could not call staff when she needed assistance and that she did not have a way to call staff because she did not have a call light. She reported having asked an unidentified staff member about her call light and being told she did not have one, and that she had been without a call light for some time, though she could not specify how long. Observation revealed that her call light was not on her bed or within her side of the room but was instead intertwined with her roommate’s call light on the roommate’s bed, contrary to the care plan intervention that required a working and reachable call light. A second resident, an older female with Alzheimer’s disease, dementia, muscle weakness, osteoporosis, unsteadiness on feet, cognitive communication deficit, dysphagia, multiple contractures, normal pressure hydrocephalus, constipation, major depressive disorder, insomnia, seizures, cataract, generalized anxiety disorder, hypothyroidism, GERD, and visual hallucinations, had an MDS indicating moderate cognitive impairment and a need for assistance with ADLs. Her care plan for musculoskeletal alteration and contractures included anticipating and meeting needs and ensuring the call light was within reach. In interview, she reported having to wait a long time for staff assistance when she did use her call light and stated she was not always able to use it because it was not near her, sometimes relying on her roommate to get staff. Observation confirmed that her call light was not in her bed but was on the floor behind a mat against the wall, making it inaccessible, in violation of both her care plan and the facility’s call light policy requiring the call device to be placed within residents’ reach before staff leave the room.
Failure to Care Plan Nebulizer Use for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing all of a resident's needs, specifically omitting the care planning for the use of a nebulizer device for one resident. The resident, a female with quadriplegia requiring total assistance for activities of daily living and with an intact cognitive status, had a physician order for Ipratropium-Albuterol via nebulizer as needed for shortness of breath or wheezing. Despite the physician order being present in the resident's records, the comprehensive care plan did not include any information or interventions related to the nebulizer use. Observations confirmed the resident was using a nebulizer, and interviews with nursing staff, including the RN, ADON, MDS nurse, and DON, revealed that the omission was due to a lack of communication and failure to update the care plan when the physician order was received. Staff acknowledged that the care plan should have been updated to reflect the new order, and that the interdisciplinary team is responsible for ensuring care plans are comprehensive and current. The facility's policy requires care plans to be reviewed and revised as needed, but this was not followed in this instance.
Failure to Implement Fall Prevention Interventions and Obtain Required Physician Orders
Penalty
Summary
The facility failed to ensure that a resident identified as a fall risk was provided with adequate accident prevention measures as outlined in his care plan. Specifically, the resident, who had severe cognitive impairment, muscle weakness, and required extensive assistance with activities of daily living, did not have a physician order for the scoop mattress used on his bed. Additionally, the fall mat, which was an intervention listed in his care plan to prevent injury from falls, was observed leaning against the wall rather than being placed alongside the bed while the resident was in it. Interviews with nursing staff, including an RN, the DON, and the ADON, confirmed that the fall mat should have been positioned next to the resident's bed whenever he was lying in it, and that a physician order was required for the scoop mattress. The facility's policy on physical restraints also indicated that such devices should only be used with appropriate medical justification and orders. The lack of proper placement of the fall mat and absence of a physician order for the scoop mattress constituted a failure to provide an environment free from accident hazards and to implement necessary interventions for accident prevention as specified in the resident's care plan.
Failure to Properly Store Nebulizer Mask for Resident Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required the use of a nebulizer. Specifically, a resident with quadriplegia and a physician's order for Ipratropium-Albuterol via nebulizer every four hours as needed was observed to have her nebulizer mask left unbagged on a nightstand when not in use. The resident's comprehensive care plan did not include a plan for nebulizer use, and her MDS assessment did not reference the need for a breathing device. Multiple staff members, including an RN, ADON, and DON, confirmed that the mask should have been bagged when not in use to prevent infection and that this was an expected practice during nursing rounds. The facility's policy on respiratory nurse training outlines the need for skilled nursing services and proper respiratory care interventions, but this was not followed in the case of the resident observed. The failure to properly store the nebulizer mask was identified through observation, interviews, and record review, and staff acknowledged that not bagging the mask could lead to bacterial buildup and infection risk.
Unattended Unlocked Treatment Cart Found Accessible to Resident
Penalty
Summary
Surveyors observed that treatment cart #1 was left unlocked and unattended, with all drawers accessible and supplies such as bandages, gauze, and scissors easily reachable. During this time, a resident in a wheelchair was seen within approximately five feet of the unattended cart. The Director of Nursing (DON) confirmed during an interview and observation that the cart was unlocked and unattended, stating that a staff member had just stepped away. The DON also acknowledged that her expectation was for the treatment cart to be locked when not in use to prevent unauthorized access. A review of the facility's policy on Medication Access and Storage indicated that all drugs and biologicals are to be stored in locked compartments, accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. The policy further specifies that medication carts and supplies must be locked or attended by authorized persons at all times. The observed failure to lock the treatment cart while unattended was not in accordance with this policy.
Failure to Provide Timely Pharmaceutical Services Upon Admission
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring the accurate acquisition, receipt, and administration of prescribed medications following their admission. One resident, with a history of seizures, congestive heart failure, diabetes, morbid obesity, hypertension, and hemiplegia, was admitted from the hospital without his discharge medication orders being obtained or available in the facility's records. As a result, he did not receive his prescribed seizure medication, Levetiracetam (Keppra), on the evening of admission and the following morning. Nursing documentation did not reflect administration of the medication or provide an explanation for the missed doses, and the resident expressed concern and distress over the missed medication, fearing the risk of seizure activity. Another resident, with diagnoses including COPD, respiratory failure with hypoxia, morbid obesity, asthma, sleep apnea, and dependence on supplemental oxygen, was also admitted without timely access to her prescribed inhalers. Despite physician orders for multiple inhalers to manage her respiratory conditions, the resident did not receive these medications as scheduled on the evening of admission and the following day. Nursing progress notes did not document administration of the inhalers or reasons for omission. The resident reported that her inhalers were not available and expressed frustration and concern, although she did not experience acute respiratory distress during the period in question. Facility policy required medications to be administered in accordance with physician orders and for staff to document any withheld or missed doses on the medication administration record (MAR), including reasons for such occurrences. The policies also outlined the need for accurate review and verification of medications upon admission. In both cases, the facility did not follow these procedures, resulting in residents not receiving essential medications as ordered by their physicians.
Resident Abuse Incident Leading to Surgery
Penalty
Summary
The facility failed to protect a resident from physical abuse by an LVN, which resulted in significant injuries requiring surgery. The incident involved a resident who was cognitively intact and had a history of mental health issues, including schizophrenia and anxiety disorder. During an altercation, the LVN reportedly pushed the resident, causing her to fall and sustain fractures to her right elbow and wrist. The resident later required surgery to address these injuries. The incident was documented in a progress note by the LVN, who claimed the resident punched her, prompting a defensive response that led to the resident's fall. The resident's injuries were not immediately reported as abuse, and it was only after another LVN noticed bruising and reported it that the facility began to address the situation. The Director of Nursing (DON) and the Administrator were informed, and the LVN involved was suspended pending investigation. Interviews with staff revealed that the LVN had previously been in-serviced on preventing and de-escalating crisis situations, as well as on abuse and neglect policies. Despite this training, the LVN's actions were deemed inappropriate, leading to her termination. The facility's policies on resident rights and abuse prevention were reviewed, highlighting the requirement for immediate reporting of any suspected abuse or neglect.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, which is a violation of their right to reasonable accommodation of needs and preferences. Resident #3, a male with severe cognitive impairment and muscle weakness, was found with his call light clipped to the privacy curtain, out of his reach. This resident required maximal assistance for daily activities and was at risk for falls due to an unstable gait. Similarly, Resident #4, who also had muscle weakness and difficulty walking, could not locate his call light, which was obstructed by his roommate's oxygen concentrator. Both residents were unable to access their call lights to request assistance, which could lead to unmet needs and potential emergencies. Interviews with staff, including RN D, the ADON, the DON, and the Administrator, revealed a consensus that call lights should always be within reach of residents to ensure their needs are met and to prevent potential emergencies. RN D acknowledged the oversight and took immediate action to place Resident #3's call light within reach. The ADON and DON both emphasized the importance of staff ensuring call lights are accessible during rounds and before leaving residents' rooms. The facility's policy also mandates that call devices be placed within residents' reach before staff leave the room. The deficiency was identified during observations and interviews conducted on the same day, highlighting a lapse in staff adherence to the facility's policy and procedures regarding call light accessibility. The staff, including CNA F, admitted to not noticing the inaccessibility of the call lights for the two residents, which could result in their needs not being communicated or met. The facility's policy, revised in 2021, clearly outlines the requirement for call lights to be within reach, yet this was not followed, leading to the deficiency noted in the report.
Failure to Prevent Catheter Bag Contamination
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary Foley catheter, which resulted in the catheter bag coming into contact with the floor. This incident involved a male resident diagnosed with neuromuscular dysfunction of the bladder, who had a suprapubic catheter in place. During an observation, it was noted that the catheter bag and its drain valve were on the floor, which was confirmed by a registered nurse who acknowledged that the floor was dirty and that the catheter bag should be secured to prevent infection. Interviews with the facility's staff, including the RN, ADON, DON, and a CNA, revealed a consensus that the catheter bag should not be on the floor to prevent potential contamination and infection. The staff acknowledged the importance of keeping the catheter bag below the bladder but off the floor, and the DON emphasized the responsibility of nurses to monitor and ensure the catheter bag's proper placement. The facility's policy on catheter care also highlighted the importance of infection control to prevent catheter-associated urinary tract infections.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for a resident diagnosed with chronic obstructive pulmonary disease (COPD). The resident's face mask for the nebulizer was not stored correctly when not in use, as it was found on top of a semi-open drawer without being bagged. The resident mentioned that the nurse did not return after the breathing treatment, and she was not informed about the necessity of bagging the mask. The nurse, RN D, acknowledged that the mask should have been bagged and admitted to not noticing the mask was left unbagged after checking the resident's oxygen saturation. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the breathing mask should be cleaned and bagged after use to prevent cross-contamination and infection. The facility's policy also indicated that respiratory equipment should be stored in a plastic bag marked with the date and resident's name. The Administrator emphasized the importance of keeping residents' equipment clean to prevent infection, although he was not a clinician. This oversight in respiratory care could potentially place residents at risk for respiratory infections.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of staff members during the care of a resident with cerebral palsy. The resident, who was always incontinent for both bowel and bladder, was observed receiving care from COTA G and PTA H. During the process, COTA G did not perform hand hygiene before donning gloves and failed to change gloves after handling soiled items, such as a soiled brief and the resident's perineal area. This lack of proper glove use and hand hygiene was observed during the transfer and cleaning of the resident, which involved contact with feces. COTA G continued to use the same gloves after they became contaminated with feces, merely wiping them off instead of changing them. This improper practice was acknowledged by COTA G, who admitted that her actions could lead to cross-contamination and infection. Similarly, CNA F, who assisted in the care, did not sanitize her hands before putting on a new pair of gloves after removing the soiled ones. Both staff members recognized the importance of changing gloves and performing hand hygiene to prevent the transfer of germs. Interviews with the ADON, DON, and the Administrator confirmed that the facility's policy required hand hygiene before and after resident care, and glove changes after contact with soiled items. The failure to adhere to these protocols during the care of the resident was acknowledged by the staff, who understood the potential for cross-contamination and infection due to their actions.
Failure to Provide Privacy Bag for Catheter
Penalty
Summary
The facility failed to treat a resident with dignity and respect by not providing a privacy bag for her catheter bag. The resident, an elderly female with obstructive and reflux uropathy, was observed with her catheter bag exposed and visible upon entering her room. This was noted during an observation and interview, where the resident did not respond to questions about her awareness of the exposed catheter bag. The facility's staff, including a registered nurse (RN), the Director of Nursing (DON), and the Assistant Director of Nursing (ADON), acknowledged the importance of using a privacy bag to maintain the resident's dignity. The RN admitted to not noticing the exposed catheter bag during her rounds, while the DON and ADON emphasized the expectation for staff to ensure catheter bags are covered to prevent embarrassment and maintain dignity. The facility's policy on dignity and respect, as well as its policy on indwelling urinary catheter care, both require the use of privacy bags for catheter drainage bags. Despite these policies, the resident's catheter bag remained uncovered, indicating a lapse in adherence to the facility's procedures and a failure to uphold the resident's right to a dignified existence.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in seven out of ten rooms and the hallway floors reviewed for cleanliness and sanitization. Observations revealed thick dirt and reddish stains along the borders of the hallway floors. In several resident rooms, air conditioning units had vents filled with black dirt debris and thick dust, and air filters were covered in dust. Additionally, there were brownish stains on walls and bathroom floors, thick dirt debris in bathroom corners, and significant ice buildup in mini fridge freezer sections. Interviews with facility staff, including the Operations Manager, Housekeeping Supervisor, and a newly hired housekeeper, indicated a lack of awareness and communication regarding the cleanliness issues. The Operations Manager was unaware of the concerns until shown photos, and the Housekeeping Supervisor acknowledged that housekeeping was responsible for cleaning the areas in question. The newly hired housekeeper stated she was not informed about the need to clean air filters until recently. The facility's cleaning policy from May 2023 states that housekeeping is responsible for maintaining equipment and keeping it as bacteria-free as possible, which was not adhered to in this instance.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, leading to potential risks of respiratory infection. Resident #35's nasal cannula was observed unbagged and improperly stored on a stuffed rabbit, contrary to the care plan that required it to be kept in a plastic bag when not in use. This oversight was confirmed by the Director of Nursing (DON), who acknowledged the risk of infection control due to the improper storage. Resident #55's face mask for his nebulizer was also found unbagged on his nightstand, despite the resident's acknowledgment of not using it for a few days. The Assistant Director of Nursing (ADON) confirmed that the mask should have been bagged to prevent infection. This lack of adherence to proper storage protocols was noted during an interview and observation. Resident #45's nasal cannula was found tangled and touching the floor, with no plastic bag available for storage when not in use. Multiple staff members, including a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), failed to notice the improper storage during their rounds. The ADON and DON both stated that the nasal cannula should be bagged to prevent cross-contamination and infection, highlighting a lapse in staff awareness and adherence to infection control procedures.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain food storage, preparation, and sanitation standards in its only kitchen, as observed during a survey. Specific deficiencies included unclean equipment such as the ice scoop and ice chest, which had visible dirt and stains. Additionally, food items in the refrigerator and freezer were not properly labeled with storage dates, lacking either the complete date or any date at all. This included fish filets, sandwiches, sliced ham, turkey, croissants, vegetable soup, mixed vegetables, gravy, diced vegetables, beef enchiladas, stir fry vegetables, and sliced carrots. Furthermore, the tea dispenser was left uncovered, and the kitchen's cooking equipment, including the fryer and warming table, was found to be dirty and stained. Interviews with the consultant dietitian and the Operations Manager revealed that the dietary manager was on leave, and there was no designated temporary manager for the kitchen. The consultant dietitian acknowledged the issues and stated that the kitchen equipment was cleaned weekly, but could not identify specific staff responsible for the kitchen's cleanliness. The Operations Manager was aware of the concerns and recognized the potential risk of illness to residents due to these deficiencies. The facility's policy on dietary services and infection control emphasized preventing food contamination, but the observed practices did not align with these standards.
Infection Control Deficiencies in Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to two residents. CNA C did not change gloves or perform hand hygiene after cleaning the resident's bottom and before handling a new brief, which could lead to cross-contamination. Additionally, CNA C placed a pericare cleanser from her pocket onto a new brief, which she acknowledged could introduce contaminants from her pocket to the clean brief. These actions were observed during care for a resident with dementia and muscle weakness, who was always incontinent for both bowel and bladder. Similarly, CNA B did not perform hand hygiene before starting incontinent care for another resident and failed to change gloves after cleaning the resident's bottom and before handling new padding and a new brief. CNA B also placed a new brief on top of an old, soiled padding, which could result in contamination of the new brief. This resident had a history of urinary tract infection and paraplegia and was always incontinent for bladder and bowel. Both CNAs admitted to not following proper hand hygiene and glove-changing protocols, despite having received in-service training on these procedures. Interviews with the ADON and DON confirmed that the facility's policy required hand hygiene before and after care, and glove changes when transitioning from dirty to clean tasks. The DON emphasized that hand hygiene is the most effective way to prevent cross-contamination and infection. The facility's policy on hand hygiene, revised in December 2023, outlines the necessity of washing hands before and after direct contact with residents, after contact with bodily fluids, and after removing gloves.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #35 by not responding to her call light within a reasonable time. Observations on 11/20/2024 showed that Resident #35's call light was in use from 11:23 am until 12:30 pm, indicating a delay of over an hour before it was addressed. Interviews with the resident and other residents revealed that staff response times to call lights ranged from 30 minutes to over an hour on weekdays and even longer on weekends. This delay in response time was corroborated by multiple staff members, including LVN-A, CNA-I, ADON G, the DON, ADM, and ADON H, who all acknowledged that call lights should be answered promptly to prevent potential harm to residents. The facility's grievance log also reflected concerns from the resident council about call lights not being answered in a timely manner, with entries dated 8/12/2024 and 9/9/2024. The facility's policy on call lights, revised on 8/3/2021, states that call lights should be answered within a reasonable time, and staff should listen to and respond to residents' requests. Despite this policy, the facility's failure to adhere to it resulted in a deficiency, as it placed residents at risk of being unable to obtain assistance when needed, potentially leading to emergencies.
Failure to Maintain Resident Privacy During Medical Treatment
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during medical treatment. Specifically, a Licensed Vocational Nurse (LVN) did not close the door while checking the resident's blood sugar and administering insulin. This oversight was observed during a survey, where the resident was visible from the hallway, compromising her privacy. The resident involved was an elderly female diagnosed with type 2 diabetes mellitus and unspecified dementia with agitation. Her care plan included interventions to reduce distractions, such as closing the door during treatments. Despite this, the LVN admitted to forgetting to close the door, acknowledging that it should be done to provide privacy and dignity to the resident. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed that the expectation was for staff to close the door or draw the privacy curtain during treatments to prevent embarrassment and maintain dignity. The facility's policy on dignity and respect also emphasized the importance of maintaining residents' privacy during examinations and treatments.
Inaccurate Assessment of Oxygen Therapy for a Resident
Penalty
Summary
The facility failed to ensure that Resident #45 received an accurate assessment reflective of her current status, specifically regarding her use of oxygen therapy. The Quarterly MDS Assessment for Resident #45, dated 11/10/2024, did not indicate that she was on oxygen therapy, despite her medical condition of respiratory failure with hypoxia and a physician's order for continuous oxygen use. This discrepancy was identified through observations, interviews, and record reviews, which showed that the resident was indeed using oxygen therapy continuously, as confirmed by both the resident and the nursing staff. Interviews with various staff members, including LVN A, ADON G, the DON, and the MDS Nurse, revealed a lack of awareness and oversight in the assessment process. LVN A confirmed the resident's continuous use of oxygen due to her respiratory issues. ADON G and the DON both acknowledged the importance of accurate assessments in ensuring appropriate care and interventions for residents. The MDS Nurse admitted to overlooking the resident's oxygen therapy in the MDS assessment, despite the presence of a physician's order and a care plan indicating the need for continuous oxygen. The facility's policy on resident assessments emphasizes the need for comprehensive, accurate, and standardized assessments documented in the clinical health record. However, the failure to accurately reflect Resident #45's oxygen therapy in the MDS assessment highlights a gap in the facility's adherence to this policy. This oversight could potentially lead to confusion in the care provided to the resident, as the MDS assessment serves as a basis for determining the necessary care and interventions.
Failure to Obtain Physician Orders for Scoop Mattress
Penalty
Summary
The facility failed to ensure the resident environment was as free of accident hazards as possible for a resident reviewed for accident hazards. Specifically, the facility did not obtain physician orders or conduct a physician assessment for the use of a scoop mattress for fall prevention before its installation for the resident. This oversight was identified during an observation where the resident was found lying on a scoop mattress without the necessary physician orders or assessment. The resident involved was an elderly male with diagnoses including seizures, syncope and collapse, and muscle weakness. He was totally dependent on assistance for activities of daily living such as transfers, toileting, and bathing. The Director of Nursing (DON) acknowledged that the scoop mattress was provided without a physician's order or assessment, sometimes at the request of family members, and recognized the potential risk of injury to the resident if he attempted to get out of bed without proper assessment.
Inappropriate Incontinent Care Leading to Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a potential risk of urinary tract infection. The resident, an elderly female with dementia and muscle weakness, was always incontinent of both bowel and bladder. During an observation, a CNA was seen performing incontinent care on the resident. The CNA initially used the correct front-to-back technique to clean the resident's front part but then reused the same wipe to clean different areas of the resident's front part, which is against the facility's policy and could lead to cross-contamination. Interviews with the CNA, ADON, and DON revealed that the CNA acknowledged the mistake and understood the risk of infection from improper cleaning. The ADON and DON confirmed that the facility's policy requires using a new wipe for each stroke to prevent cross-contamination. The DON mentioned that sometimes wipes could be reused if not heavily soiled, but to ensure safety, they should not be reused. The facility's policy emphasizes cleaning from the cleanest to the dirtiest area to prevent infection.
Failure in G-Tube Care and Management
Penalty
Summary
The facility failed to ensure proper care and management of a resident with a gastrostomy tube, leading to potential risks of infection and accidental dislodgement of the tube. The resident, a female with severe cognitive impairment and dysphagia, was observed to have been administered medication via a g-tube using a syringe that had not been replaced daily as required. The LVN responsible for the medication administration did not check the date on the syringe, which was supposed to be changed every 24 hours to prevent infection. The syringe used was dated two days prior, indicating a lapse in following the physician's order and facility policy. Additionally, the facility did not ensure the resident wore an abdominal binder as per the physician's order. The binder is intended to secure the gastrostomy tube and prevent accidental pulling. During the observation, the resident was not wearing the binder, and there was no binder present in the room. The LVN mentioned that the resident refused to wear the binder, but there was no documentation of such refusal, and the resident herself stated she was never asked about it. This lack of adherence to the physician's order and absence of documentation further contributed to the deficiency. Interviews with the ADON and DON confirmed the expectation for syringes to be changed daily and for the abdominal binder to be worn if ordered. The ADON acknowledged the failure of the night nurse to replace the syringe and the LVN's responsibility to verify its replacement. The DON emphasized the importance of following the correct procedures for g-tube care to prevent infection and ensure the safety of the resident. The facility's policy on gastrostomy tube care clearly outlines the need for daily syringe replacement and the use of an abdominal binder, which were not adhered to in this case.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by video footage showing inappropriate conduct by a CNA. The resident, who was non-verbal and had severe cognitive impairments, was observed trying to cover herself while the CNA undressed her and engaged in inappropriate touching for over eight minutes. This incident was reported to the facility's Administrator in Training and law enforcement, leading to the resident's removal from the facility. The resident had a history of multiple diagnoses, including dementia, major depressive disorder, and muscle weakness, and was dependent on staff for all activities of daily living. The facility's records indicated that the resident was unable to communicate verbally and required complete assistance with personal care. Despite these vulnerabilities, the facility did not ensure the resident's safety, resulting in a serious breach of her rights and dignity. Interviews with facility staff revealed that they were aware of the procedures for reporting abuse but failed to prevent the incident. The CNA involved had no prior incidents or warnings and was even recognized as employee of the month. The facility's investigation was ongoing at the time of the report, and the CNA was suspended pending the outcome. The failure to protect the resident from abuse highlighted significant lapses in the facility's oversight and monitoring of staff interactions with residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, as evidenced by an incident involving a resident who was sexually abused by a Certified Nursing Assistant (CNA). The incident was captured on video, showing the CNA undressing the resident and inappropriately touching her for over eight minutes. The resident, who was non-verbal and had severe cognitive impairments, was unable to communicate the abuse, which was reported by a confidential interviewee to the facility's Administrator in Training and law enforcement. The resident involved in the incident had multiple diagnoses, including dysphagia, cognitive communication deficit, dementia, psychotic disorder with delusions, paranoid schizophrenia, major depressive disorder, and muscle weakness. She was dependent on staff for all activities of daily living and was incontinent of bowel and bladder. The facility's care plan for the resident required staff to provide incontinent care after each episode, indicating her vulnerability and reliance on staff for personal care. Despite the facility's policy on abuse prevention and prohibition, the staff failed to protect the resident from abuse. The facility's investigation was ongoing at the time of the report, and the CNA involved was suspended pending the investigation. Interviews with various staff members revealed that they were aware of the procedures for reporting abuse and had received training on the facility's abuse policy. However, the incident highlighted a significant lapse in the implementation of these policies, resulting in the resident's abuse and the facility's failure to ensure a safe environment for its residents.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, a [AGE] year-old female with a history of stroke, who was always incontinent of bladder and bowel and required extensive assistance from two staff members for incontinence care and bed mobility. Despite the care plan indicating the need for two staff members, an observation revealed that CNA A provided incontinence care alone. During an interview, CNA A acknowledged that Resident #1 was a two-person assist but proceeded alone as the other staff member left. The Director of Nursing (DON) stated that the care plan was a guide and the number of staff required could change based on the resident's participation level during care. The facility's policy on Comprehensive Resident Centered Care Plan, revised in January 2022, mandates the development and implementation of a baseline care plan that includes instructions for effective and person-centered care. However, the facility did not adhere to this policy, as evidenced by the failure to ensure two staff members performed incontinence care for Resident #1, potentially placing residents at risk for not receiving care consistent with their care plan.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, as evidenced by the actions of CNA A during incontinence care for a resident. The resident, who was always incontinent of bladder and bowel and had a history of frequent urinary tract infections, was observed to be soiled with urine that had gone through the bed sheets to the mattress. CNA A did not perform hand hygiene between glove changes and did not clean the urine on the mattress before placing clean sheets and a brief on the resident. CNA A admitted to not performing hand hygiene due to the lack of hand sanitizer and not cleaning the mattress because it would have been difficult without additional help, despite being trained to do so. The Director of Nursing (DON) confirmed that staff were expected to perform hand hygiene between glove changes and clean the mattress if it had urine on it, emphasizing the importance of these actions in preventing infection. The facility's policy on incontinence care, dated March 2017, also required staff to remove gloves and wash hands. This failure to adhere to infection control protocols could place residents at risk for infection during incontinence care.
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.
