White Settlement Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in White Settlement, Texas.
- Location
- 7820 Skyline Park Dr, White Settlement, Texas 76108
- CMS Provider Number
- 455475
- Inspections on file
- 46
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at White Settlement Nursing Center during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments did not consistently receive required two-hour rounding, incontinence care, or assistance with ADLs as outlined in their care plan and facility policy. Staff failed to ensure the call light was within reach, did not always respond to requests for help, and sometimes left the resident in soiled briefs for extended periods. Observations and interviews confirmed that staff were sometimes inattentive and did not follow established rounding and care protocols.
A resident with severe cognitive and physical impairments was found with their call light on the floor and out of reach, despite care plans and facility policy requiring accessibility. Staff interviews and observations confirmed that call lights were not consistently kept within reach, rounds were not performed as expected, and call light responses were delayed or ignored, resulting in unmet care needs.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that a resident received treatment and supports for daily living in a safe manner. The report does not include further details about the specific circumstances or individuals involved.
Several residents were housed in rooms where temperatures exceeded comfortable levels, with some rooms reaching up to 82°F. Despite the use of multiple fans and residents relocating to cooler common areas, many reported discomfort and signs of overheating. The facility was aware of ongoing HVAC issues, but adequate cooling was not consistently provided.
Two residents with cognitive and behavioral health diagnoses were involved in a physical altercation over a purse, during which one resident struck the other in the face despite staff intervention. The incident revealed a failure to prevent resident-to-resident abuse, as required by facility policy, and resulted in a deficiency related to resident protection from abuse and neglect.
The facility did not follow the prescribed menu for a lunch meal, omitting pureed dinner rolls for residents on pureed diets and substituting greens for broccoli florets without proper documentation or posting. Dietary Managers confirmed the oversight and acknowledged that facility policy requires all residents to receive the same meal and for substitutions to be documented and reviewed by the Dietician.
Several residents did not have full visual privacy in their rooms due to missing or malfunctioning privacy curtains and window blinds. Some residents lacked curtains at the foot of their beds, while others had curtains that did not fully extend or were tied up, and one resident had broken window blinds exposing them to an outside area. Staff interviews revealed that maintenance only addressed these issues when reported, and there was no routine check for privacy coverage, despite facility policy requiring privacy and dignity for all residents.
The facility did not maintain an effective pest control program, as evidenced by repeated observations of live cockroaches in a resident room, a community bathroom, and the activity room. Staff and residents reported ongoing issues with roaches despite regular pest control treatments, and facility records showed repeated need for treatment in multiple areas. The administrator and maintenance director acknowledged persistent problems, with contributing factors including food storage in resident rooms and inconsistent housekeeping.
A resident with severe cognitive impairment and blindness did not receive necessary nail care, resulting in excessively long fingernails. Despite care plans and facility policy requiring regular nail care, staff failed to trim the resident's nails due to confusion over responsibility and lack of assessment during scheduled showers.
A resident with a gastrostomy tube was not provided enteral nutrition according to physician orders, as nursing staff administered an additional two hours of feeding downtime each day that was not prescribed. This deviation was not identified due to lack of review of updated orders after the resident's hospital readmission, resulting in the resident receiving only 20 hours of feeding instead of the ordered 22 hours. The issue was discovered after significant weight loss was noted and staff interviews revealed confusion about the correct feeding schedule.
A resident with a tracheostomy did not have an emergency trach kit, including a bag valve mask and the next lower size trach tube, readily available at the bedside as required by facility policy and the care plan. Nursing staff and administration confirmed the absence of these supplies and acknowledged their responsibility to ensure their presence and accessibility, with facility policy mandating these items always be at the bedside for residents with tracheostomy status.
A resident with a feeding tube received five medications mixed together and administered at once by an RN, rather than each medication being given separately with water flushes as ordered. This resulted in an 11% medication error rate, exceeding the acceptable threshold, and was confirmed by both staff and the resident as a routine practice. The RN acknowledged combining medications to save time, and the DON stated the RN had not been checked off on proper tube medication administration.
CNAs failed to wear required PPE, including gowns and gloves, while transferring a resident with a urinary catheter who was on Enhanced Barrier Precautions. One CNA wore only gloves, while the other wore no PPE, despite clear signage and facility policy requiring both gown and gloves for high-contact care activities. The DON confirmed that proper PPE should have been used during the transfer.
A resident with a history of hypertension had an extremely high blood pressure reading of 216/114, which was not reported to the physician or responsible party by the facility staff. The resident, who had multiple health conditions, later called 911 due to feeling unwell and was hospitalized with pneumonia. The facility's policy to notify the physician of significant changes in condition was not followed.
A resident with multiple health issues, including hypertension, had an extremely high blood pressure reading that was not reported to the nurse by the medication aide, leading to a lack of immediate medical evaluation. The resident later called 911 and was hospitalized with pneumonia. The facility's failure to follow protocols for abnormal vital signs placed residents at risk of delayed treatment.
A resident with a history of mental health issues received a mentally and emotionally abusive text message from an LVN's phone, causing fear for her personal safety. The facility failed to prevent this abuse, leading to the resident feeling scared and unprotected.
The facility failed to maintain a sanitary environment, with persistent urine odors on Station 1, dirty privacy curtains for two residents, and unclean wheelchairs. Staff interviews revealed inconsistent cleaning practices and a lack of effective systems to address these issues, contributing to unsanitary conditions.
The facility failed to provide adequate pharmaceutical services, including maintaining accurate narcotic records and removing expired medications from carts. An expired bottle of Aspirin was found, and a nurse failed to log the administration of a narcotic, leading to potential drug diversion.
The facility failed to ensure that insulin pens on two medication carts were dated with an opening date. Observations revealed that insulin vials on the station 1 South and station 3 medication carts were opened and partially used without an opening date. Interviews with the responsible LVNs and the Interim DON confirmed that this oversight could lead to the use of expired and ineffective insulin.
A resident with severe cognitive impairment and multiple diagnoses had an ophthalmology referral that was not scheduled by the responsible LVN. The Interim DON and Administrator confirmed that the referral was not made, and the facility's policy mandates staff education on resident rights and proper care.
A resident with a Stage 4 pressure ulcer was found without a dressing, despite having informed staff. The facility staff, including the LVN and CNA, were unaware or forgot to address the issue, and the Interim DON had not conducted wound care in-services. This failure to follow wound care protocols placed the resident at risk of infection and delayed healing.
The facility failed to complete post-dialysis assessments for two residents, despite care plans and physician's orders requiring monitoring of vital signs. Interviews revealed a lack of awareness and oversight among nursing staff and management, leading to serious health risks for the residents.
The facility failed to act upon the pharmacist's recommendation for a gradual dose reduction (GDR) of a resident's psychotropic medication, Duloxetine HCl. The resident had not had a GDR attempt within the last six months, and the procedure was not completed due to the absence of a DON from October 2023 to February 2024, leading to the risk of over-medication.
A facility failed to provide a working call light system for a resident with significant medical conditions, leading to potential delays in assistance. Staff removed the call light due to frequent accidental activations, but acknowledged that every resident should have one within reach. The issue was not addressed until identified during a survey, despite the facility's policy requiring call lights for all residents.
Failure to Provide Timely ADL and Incontinence Care Due to Missed Rounds and Inaccessible Call Light
Penalty
Summary
Facility staff failed to provide necessary services for a resident who was unable to carry out activities of daily living (ADLs), as required by both facility policy and the resident's care plan. The resident, a male with severe cognitive impairment and multiple diagnoses including cerebral infarction, epilepsy, ALS, and incontinence, required extensive to total assistance with mobility, hygiene, and toileting. The care plan specified that two staff members were needed for assistance, frequent rounding was required to anticipate needs, and incontinent care was to be performed every two hours. Despite these requirements, interviews and observations revealed that staff did not consistently perform two-hour rounds or ensure the resident's call light was within reach. The resident and his roommate reported that staff often failed to respond to call lights, sometimes turned off the call light without addressing needs, and left the resident in soiled briefs for extended periods. The roommate frequently had to use his own call light or seek staff assistance in the hallway. Observations confirmed that staff were sometimes seated in the hallway using their cell phones instead of attending to residents' needs, and the resident was unable to reach his call light when assistance was needed. Staff interviews indicated a lack of consistent adherence to rounding schedules and responsibilities. While some CNAs described their routines, there was confusion about assignments and a lack of follow-through in ensuring call lights were accessible and needs were met. Facility in-service records confirmed that staff were trained to perform rounds and incontinent care every two hours and to keep call lights within reach, but these practices were not consistently implemented for this resident.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident's call light was found on the floor, out of reach, while the resident was in bed. The resident, who had significant medical conditions including cerebral infarction, epilepsy, severe cognitive impairment, dysphagia, muscle weakness, and a history of repeated falls, was dependent on staff for activities of daily living and required frequent assistance. The care plan for this resident specifically included interventions to keep the call light within reach and to anticipate and meet the resident's needs due to their high risk for falls and impaired communication. Observations and interviews revealed that staff did not consistently ensure the call light was accessible to the resident. The resident reported that staff did not round every two hours as expected and did not always ensure the call light was within reach. There were also instances where staff entered the room, turned off the call light, and left without addressing the resident's needs. The resident's roommate corroborated these statements, noting that staff did not always answer the call light and sometimes left the resident unattended for extended periods. The roommate often had to use his own call light or seek staff assistance in the hallway for the resident. Further interviews with CNAs, the DON, ADON, and the facility administrator confirmed that staff were expected to check call lights during rounds and ensure they were within reach, but these expectations were not consistently met. Staff acknowledged the importance of timely call light response and accessibility but admitted to lapses in practice. Facility policy required call lights to be placed near residents and never on the floor, but this was not followed in the case of the resident in question.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved, are not provided in the report.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels within the required range of 71 to 81 degrees Fahrenheit for 16 out of 26 residents reviewed. Multiple observations revealed that residents' rooms were being cooled with several fans, some of which were purchased by the residents or their families, while others were provided by the facility. Despite these efforts, ambient temperatures in affected rooms ranged from 75 to 82 degrees Fahrenheit, with several residents reporting discomfort, sweating, and the need to leave their rooms during the warmer parts of the day. Residents frequently relocated to common or dining areas where the air conditioning was functioning, as their own rooms became too hot to occupy comfortably. Interviews with residents confirmed that the air conditioning in certain sections had not been working for several weeks, and the facility was aware of the issue. The Maintenance Director stated that the HVAC unit servicing the affected rooms had been partially repaired but was still not cooling adequately, pending further repairs. The Administrator acknowledged the ongoing HVAC issues and indicated that staff were providing ice and water to residents in the affected areas. The facility's policy required living spaces to be comfortable and temperature-controlled, but this standard was not met for the residents in the impacted rooms.
Failure to Prevent Resident-to-Resident Abuse During Altercation
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, misappropriation of property, and exploitation, as evidenced by an incident involving two residents. One resident, who had dementia, bipolar disorder, and schizoaffective disorder with moderate cognitive impairment, was involved in a physical altercation with another resident who was cognitively intact but had a history of schizophrenia and impaired vision. The altercation began when the cognitively intact resident believed the other resident had taken her purse, leading to a verbal dispute and a physical struggle over the purse. During the incident, staff observed the two residents tugging on the purse and intervened to separate them. Despite staff intervention, the cognitively intact resident struck the other resident in the face with a closed fist. Immediate assessment by nursing staff found no pain or injury, and the incident was reported to the appropriate facility leadership. The resident who was struck had no recollection of the event, and her responsible party reported no visible injuries or concerns about her care. Interviews with staff and review of care plans indicated that the resident who initiated the physical contact had no prior history of aggression, and the resident who was struck had a known pattern of entering other residents' rooms and taking items. The facility's policy required prevention and prohibition of abuse, neglect, and exploitation, but the incident demonstrated a failure to prevent resident-to-resident abuse in this instance.
Failure to Follow Prescribed Menu and Document Substitutions for Pureed Diets
Penalty
Summary
The facility failed to follow the prescribed menu for one observed lunch meal, specifically for residents on pureed diets. During the lunch service, pureed dinner rolls were not prepared or served to residents who required pureed meals, and greens were substituted for broccoli florets without proper documentation or posting of the substitution. Both the Dietary Manager and a visiting Dietary Manager from a sister facility confirmed that the omission of the pureed dinner roll was due to staff oversight and that facility policy requires all residents to receive the same meal and for any substitutions to be posted and documented. Review of the facility's menu confirmed that the planned meal included pork roast loin, buttered broccoli florets, boiled potato, dinner roll, and chocolate pudding. The facility's policy on menu changes and substitutions requires that any variation from the planned menu be documented and reviewed by the Dietician, with substitutions made using foods of equivalent nutritive value. No documentation or posting of the substitution was observed, and the Dietary Managers acknowledged the importance of following the menu to ensure residents receive adequate nutrition.
Failure to Ensure Full Visual Privacy in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident rooms provided full visual privacy for five residents, as required for maintaining dignity and personal space. Observations revealed that several residents either lacked privacy curtains at the foot of their beds, had curtains that did not fully extend due to missing hangers or malfunctioning tracks, or had curtains tied up and not in use. In one case, a resident was also missing multiple slats from window blinds, resulting in a lack of privacy from an outside smoking area. Residents expressed dissatisfaction with the lack of privacy, noting that it had persisted for extended periods, and some stated a preference for full privacy, especially when changing clothes. Interviews with staff indicated that maintenance was responsible for hanging and repairing curtains, while housekeeping handled cleaning and replacement when needed. However, maintenance only addressed curtain or track issues when they were reported, and there was no routine check for coverage or functionality. Nursing staff and supervisors acknowledged the importance of privacy curtains and window blinds for resident dignity, but also indicated that missing or broken items were not always promptly reported or addressed. Review of the facility's policy confirmed the requirement to maintain privacy and dignity for residents.
Failure to Maintain Effective Pest Control Program Resulting in Cockroach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live cockroaches in multiple areas, including one resident room, a community bathroom, and the activity room. Observations over several days revealed live roaches running in a resident's room, in the community bathroom adjacent to the activity room, and by the water dispenser in the activity room. Multiple live roaches were also seen in the community bathroom, with some moving into the hallway. Review of the pest control log indicated ongoing issues, with repeated treatments for American roaches in various locations, including staff restrooms, nurses' stations, and resident rooms. Interviews with residents and staff confirmed the persistent presence of roaches, particularly in the bathroom next to the activity room, despite regular pest control treatments. Staff noted that the problem persisted regardless of the frequency of treatments, and the administrator acknowledged ongoing difficulties in controlling the infestation, attributing some of the challenges to residents storing food in their rooms and housekeeping not maintaining cleanliness. The facility's policy requires an effective pest control program, but the observed and reported conditions indicate that the program was not successful in eradicating or containing the pest problem.
Failure to Provide Timely Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, blindness, and multiple medical diagnoses, including hyperlipidemia, seizure disorder, cataracts, glaucoma, and macular degeneration, did not receive necessary assistance with personal hygiene, specifically nail care. The resident required partial to moderate staff assistance for personal hygiene, as documented in the care plan, which included regular nail care. Observations on two consecutive days revealed the resident's fingernails were about a half-inch long, and the resident expressed discomfort and a desire to have his nails cut. Interviews with staff indicated confusion regarding responsibility for nail care, particularly concerning whether the resident was diabetic, which would require a nurse rather than a CNA to perform the task. The CNA assigned to the resident did not check or trim the resident's nails during scheduled showers, and the DON confirmed that nail care should be provided at least weekly by CNAs unless the resident is diabetic. The facility's nail care policy outlined the procedure for nail care, but it was not followed in this instance, resulting in the resident's nails remaining untrimmed.
Failure to Follow Physician Orders for Enteral Feeding Downtime
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a gastrostomy tube was provided with appropriate treatment and services in accordance with physician orders. Specifically, nursing staff did not follow the prescribed feeding downtime for the resident, instead providing an additional two hours of downtime each day that was not ordered by the physician. This deviation from the physician's orders was not identified or corrected by the nursing staff, as the nurse responsible for the resident was unaware of the updated orders following the resident's readmission from the hospital. The nurse continued to follow the previous downtime schedule and did not review the current physician orders upon the resident's return. The resident in question was a male with a history of nontraumatic intracerebral hemorrhage, chronic respiratory failure with hypoxia, unspecified cirrhosis of the liver, and gastrostomy status. He was nonverbal and unable to answer questions. His care plan and physician orders specified continuous enteral feeding for 22 hours per day, with a scheduled downtime from midnight to 2 AM. However, observations and interviews revealed that the resident was routinely given an additional two-hour downtime from 10 AM to noon, resulting in a total of four hours of downtime daily. This practice was not in accordance with the current physician orders and was not communicated to or recognized by the interdisciplinary team. The discrepancy in feeding times coincided with a significant, unexplained weight loss for the resident, as documented by multiple weight checks. While staff and the dietitian questioned the accuracy of the scale and did not attribute the weight loss solely to the additional downtime, the failure to follow physician orders for enteral feeding was confirmed. The facility's policy required that enteral feedings be administered per physician order, but this was not adhered to in the resident's case. Interviews with nursing, dietary, and therapy staff further confirmed a lack of awareness and communication regarding the resident's current feeding schedule and physician orders.
Failure to Maintain Emergency Tracheostomy Kit at Bedside
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not have an emergency tracheostomy kit, including a bag valve mask and the next lower size trach tube, readily available at the bedside as required by facility policy and the resident's care plan. The resident, a female with a history of seizure disorder, respiratory failure, tracheostomy status, and diabetes, was totally dependent on staff for activities of daily living and was rarely or never understood. Her care plan specifically directed that an extra trach tube be kept at the bedside and that staff monitor for signs of respiratory distress. During observation of tracheostomy care, it was noted that there was no emergency trach kit at the resident's bedside. The nurse providing care confirmed that the kit, which should include a bag valve mask and the next lower size trach tube, was not easily accessible due to disorganization of supplies. The nurse also stated she had not seen the emergency kit in the resident's room during her four weeks of employment and acknowledged it was her responsibility, along with others, to ensure the kit was present and accessible each shift. Interviews with the ADON and DON confirmed that facility policy required an emergency trach kit and the next lower size trach tube to be easily accessible in the rooms of residents with tracheostomy status. Both leaders recalled the kit being present earlier but believed it may have been discarded after falling on the floor during room adjustments. They agreed it was the responsibility of nursing staff and administration to check for these items daily and to report any missing supplies. Review of the facility's policy further confirmed the requirement for these emergency supplies to always be present at the bedside.
Medication Error Rate Exceeds 5% Due to Improper Administration via Gastric Tube
Penalty
Summary
The facility failed to ensure that medication error rates remained below 5 percent, as evidenced by an 11% error rate (5 errors out of 44 opportunities) during medication administration for one resident. Specifically, a registered nurse (RN) combined five different medications and administered them together via a gastric tube, rather than administering each medication separately with a water flush between each, as ordered by the physician and outlined in facility policy. This practice was observed during a morning medication pass, and the resident confirmed that medications were always given in this manner. The resident involved was a male with a history of stroke, cognitive impairment, and required a gastric tube for all nutrition and medication administration. Physician orders and the facility's policy required each medication to be prepared and administered separately, with water flushes before and between each medication to prevent tube clogging. The RN admitted to combining medications to save time during busy shifts, despite knowing this was not the correct procedure. The DON confirmed that the RN had not yet been checked off on proper gastric tube medication administration.
Failure to Follow Enhanced Barrier Precautions During Resident Transfer
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to follow established infection prevention and control protocols while transferring a resident who was on Enhanced Barrier Precautions (EBP) due to a urinary catheter and risk for urinary tract infections. During the transfer from wheelchair to bed using a mechanical lift, CNA A wore gloves but did not wear a gown, and CNA B did not wear any personal protective equipment (PPE) at all. The resident’s care plan and signage outside the room clearly indicated the need for gown and gloves during high-contact care activities, including transfers, for residents on EBP. Interviews with the CNAs revealed that CNA A was aware of the requirement but forgot to don the gown, while CNA B was unaware that the resident was on EBP and therefore did not use any PPE. The Director of Nursing (DON) confirmed that both CNAs should have worn gloves and gowns during the transfer, as per facility policy and posted instructions. Facility policy specified that EBP requires gown and gloves for high-contact activities for residents with indwelling medical devices, such as urinary catheters.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's physical status. Specifically, the facility did not notify the physician or responsible party when a resident's blood pressure was recorded at 216/114, which is considered extremely high. This oversight was identified during a review of the resident's records, which showed no documentation of a re-check of the blood pressure or any notification to the physician or responsible party. The resident involved was a male with a history of hypertension, type II diabetes, chronic kidney disease, and mild dementia, among other conditions. The resident was dependent on staff for most activities of daily living and had a care plan in place to monitor and manage his hypertension. Despite this, the elevated blood pressure reading was not addressed appropriately, and the resident later called 911 himself due to feeling unwell, leading to his transport to the hospital where he was diagnosed with pneumonia. Interviews with facility staff revealed that the medication aide who recorded the high blood pressure did not report it to the nurse, and the nurse did not take further action to notify the physician. The Director of Nursing (DON) was unaware of the elevated blood pressure until after the resident had been hospitalized. The facility's policy required immediate notification of the physician and responsible party for significant changes in a resident's condition, which was not followed in this instance.
Failure to Follow Protocols for Abnormal Vital Signs
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not follow protocols for abnormal vital signs when a medication aide did not notify the nurse after a resident's blood pressure was recorded at 216/114, and there was no re-check to ensure accuracy or determine if further treatment was needed. This oversight placed all residents at risk of a delay in medical evaluation and treatment. The resident involved was an elderly male with multiple diagnoses, including hypertension, type II diabetes, and mild dementia. His care plan indicated he was at risk for fluctuations in blood pressure and required monitoring for side effects of antihypertensive medications. On the day in question, the resident's blood pressure was recorded as extremely high, but the medication aide did not report this to the nurse, and no further action was taken to address the elevated reading. Interviews with staff revealed that the medication aide believed she had reported the high blood pressure to the nurse, but there was no documentation to support this. The nurse on duty stated that if she had been informed, she would have rechecked the blood pressure and notified the physician. The facility's policy required immediate notification of the physician for significant changes in a resident's condition, which did not occur in this instance. The resident later called 911 himself due to feeling unwell and was transported to the hospital, where he was diagnosed with pneumonia.
Failure to Protect Resident from Mental and Emotional Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when an LVN sent the resident a mentally and emotionally abusive text message. The resident, who had a history of schizophrenia, bipolar disorder, anxiety, and vascular dementia, received a text message from the LVN's phone that contained derogatory and threatening language. This incident caused the resident to experience fear for her personal safety. The abusive text message was discovered when the resident showed it to another LVN, who then reported it to the facility's administrator. The administrator confirmed that the text message was sent from the LVN's phone number and took immediate action by notifying the police and terminating the LVN's employment. The resident expressed that she felt scared and unprotected following the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was found that the facility did not adequately prevent the abuse from occurring. The report highlights the failure of the facility to protect the resident from mental and emotional abuse, as well as the subsequent fear and distress experienced by the resident.
Facility Fails to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable environment for residents. Observations revealed a strong smell of urine permeating Station 1, particularly from room [ROOM NUMBER] through room [ROOM NUMBER]. During a confidential resident group interview, several residents confirmed the persistent urine odor, stating that housekeeping did not always clean properly. Staff interviews indicated awareness of the issue but revealed inconsistent and inadequate measures to address the odor, such as spraying air fresheners instead of thorough cleaning. The Housekeeping Supervisor and Interim DON acknowledged the problem but cited staffing shortages and improper handling of soiled linens as contributing factors. The Administrator expressed expectations for a clean environment but did not provide evidence of effective solutions being implemented. The failure to maintain a sanitary environment was evident in the persistent urine odor and inadequate cleaning practices on Station 1. The facility also failed to ensure that privacy curtains for two residents were clean. Observations of Resident #15 and Resident #59's rooms revealed privacy curtains with dried brown substances. Both residents acknowledged the dirty curtains, with Resident #59 explicitly stating that it was the staff's responsibility to clean them. Staff interviews confirmed that the curtains were dirty and that there was no effective system in place for regular cleaning or replacement. The Housekeeping Manager admitted to a backlog in curtain changes due to staff shortages and outdated curtains. The DON and Administrator were unaware of the specific issues with the curtains but reiterated that housekeeping was responsible for maintaining a clean environment. The lack of a systematic approach to curtain maintenance contributed to the unsanitary conditions in the residents' rooms. Additionally, the facility failed to maintain residents' wheelchairs in a sanitary condition. During a confidential resident group interview, several residents reported that their wheelchairs were not being cleaned, with visible dust buildup on various parts of the wheelchairs. Staff interviews revealed confusion and inconsistency regarding the responsibility for cleaning wheelchairs, with night shift staff being nominally responsible but no clear system or log in place to ensure the task was completed. The Maintenance Manager and Interim DON acknowledged the issue but did not provide evidence of effective oversight or corrective measures. The Administrator was unaware of complaints about dirty wheelchairs and cited dignity concerns as a potential risk. The failure to maintain clean wheelchairs was evident in the residents' reports and observations of dirty wheelchairs during the survey.
Failure to Provide Adequate Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, specifically in the management of medication carts and narcotic records. On one occasion, a nurse's medication cart contained an expired bottle of Aspirin 81mg tablets, which had an expiration date of 09/2023. The nurse responsible for the cart admitted that it was her duty to check for expired medications every other week, but she had not done so in this instance. Additionally, the facility's Interim DON acknowledged that the process for auditing medication carts had only recently been implemented and was not yet fully operational. This lapse in procedure could result in the administration of ineffective medications to residents. In another instance, the facility failed to maintain accurate narcotic records for a resident who was prescribed Hydrocodone-Acetaminophen 5-325 mg for pain management. The narcotic administration record showed a discrepancy between the recorded and actual count of the medication. A nurse admitted to administering the medication but failing to sign off on the narcotic administration log, which could lead to potential drug diversion. The Interim DON confirmed that nurses were responsible for logging narcotic administration and that failure to do so could result in missing doses for residents. The facility's policy on medication administration and documentation was not adequately followed, leading to these deficiencies.
Failure to Date Insulin Pens Upon Opening
Penalty
Summary
The facility failed to ensure that insulin pens on two medication carts were dated with an opening date. During an observation, it was found that one insulin vial of Novolog Subcutaneous Solution 100 unit/ml on the station 1 South medication cart and one insulin vial of Novolog Subcutaneous Solution 100 unit/ml and one insulin vial of Humalog Subcutaneous Solution 100 unit/ml on the station 3 medication cart were opened and partially used without an opening date. Interviews with the LVNs responsible for these carts revealed that it was the nurses' responsibility to date the insulin pens upon opening, but this was not done. Both LVNs acknowledged the risk of not dating the insulin, which includes not knowing when the insulin expires and its potential ineffectiveness in controlling blood sugar levels. Both LVNs had completed training on medication storage and administration but failed to adhere to the protocol. The Interim DON confirmed that nurses were responsible for dating the insulin after opening and that a new auditing program had been initiated for the night shift to check the carts on weekends. However, this process had only recently started, and the Interim DON had not yet conducted an in-service training on expired medications and labeling insulin. Another LVN, who had recently changed roles, stated that she was no longer able to audit the carts and expected the new ADON to take over this responsibility. The facility's current Insulin Management Process policy, dated September 2015, did not address the requirement for opening dates on insulin vials.
Failure to Schedule Ophthalmology Appointment
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistance in making an ophthalmology appointment. Resident #74, who has severe cognitive impairment and multiple diagnoses including dementia, seizures, and major depressive disorder, had an order for an ophthalmology referral dated 03/08/24. However, no progress notes indicated that any staff member attempted to schedule the appointment. LVN E, who was responsible for Resident #74, confirmed that no appointment had been scheduled since the referral was made on 02/20/24. The Interim DON revealed that the expectation was for LVN E to either make the appointment herself or ask the Social Worker or Administrator to do so. However, LVN E did not inform the Administrator, and there was no Social Worker at that time. The Administrator confirmed that it was the charge nurse's responsibility to follow up on the referral and acknowledged that failing to do so could result in the resident not receiving necessary services. The facility's Resident's Rights policy mandates that all staff members are educated on the rights of residents and the facility's responsibility to properly care for them.
Failure to Ensure Proper Wound Care for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to ensure necessary treatment and services to promote healing for a resident with a Stage 4 pressure ulcer. The resident, who had multiple diagnoses including quadriplegia and muscle wasting, was observed without a dressing on her pressure ulcer. The resident mentioned that the wound care doctor had removed her wound vac the previous day and that she had informed the staff about the missing dressing, but no one had come to apply a new one. The observation confirmed that the pressure ulcer was not covered, and the resident's brief was wet, indicating a lack of proper wound care management. Interviews with the staff revealed a lack of awareness and communication regarding the resident's wound care needs. The LVN was unaware that the dressing had come off, and the CNA admitted to noticing the missing dressing during morning care but forgot to notify the nurse. The Interim DON acknowledged that she had not conducted any in-services on wound care since her arrival six weeks prior and emphasized the importance of following physician orders and PRN orders to prevent infection and promote healing. The Treatment Nurse confirmed that the resident had a physician's order for specific wound care treatments, including the application of Santyl and Dakin's gauze, but had not been informed that the dressing had come off. The facility's policy on wound management was reviewed, which outlined the procedures for dressing changes and emphasized the need for timely intervention if a dressing becomes soiled or dislodged. The failure to adhere to these protocols placed the resident at risk of infection and delayed healing of the pressure ulcer.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that residents who required dialysis received appropriate post-dialysis assessments. For Resident #69, the facility did not complete post-dialysis assessments after the resident returned from dialysis treatment. Despite the care plan and physician's orders indicating the need for monitoring vital signs post-dialysis, the electronic health record (EHR) showed no documentation of these assessments. Interviews with the nursing staff revealed a lack of awareness regarding the missing documentation, although they claimed to have taken the necessary vital signs. The Interim DON and ADON were also unaware of the missing documentation and emphasized the risks associated with not monitoring post-dialysis vital signs, such as low blood pressure and shortness of breath. Similarly, the facility failed to complete post-dialysis assessments for Resident #92. The resident's care plan and physician's orders also required monitoring of vital signs post-dialysis, but the dialysis communication forms lacked this information. Interviews with the nursing staff and management revealed a similar lack of awareness and oversight. The Interim DON admitted that the admitting nurse was not strong and that a seasoned ADON had been hired to address these issues. However, the Interim DON had not conducted any training since taking the position. The facility's policies on dialysis vascular access methods and following physician orders were not adhered to, as evidenced by the lack of documentation and monitoring of post-dialysis vital signs for both residents. The failure to follow these policies could lead to serious health risks for the residents, including low blood pressure, bleeding, and shortness of breath. The nursing staff and management acknowledged the importance of these assessments but failed to implement them consistently.
Failure to Follow Pharmacist's Recommendations for Drug Regimen Review
Penalty
Summary
The facility failed to act upon the recommendations of the pharmacist regarding a drug regimen review (DRR) for a resident. Specifically, the facility did not follow up on a recommendation to attempt a gradual dose reduction (GDR) for the resident's psychotropic medication, Duloxetine HCl. The resident, who had multiple diagnoses including Type 2 diabetes mellitus with diabetic nephropathy, osteomyelitis, peripheral vascular disease, heart failure, and depression, had not had a GDR attempt since 05/26/23. The interim Director of Nursing (DON) acknowledged that the resident should have had a GDR attempt within the last six months, but this was not done due to the absence of a DON from October 2023 to February 2024. The facility's policy, revised in October 2018, requires monthly drug regimen reviews and timely follow-up on pharmacist recommendations. The interim DON stated that the Assistant Directors of Nursing (ADONs) were responsible for ensuring that the pharmacist's recommendations were given to the physician for approval and then uploaded to the resident's chart. However, this procedure was not completed during the period when there was no DON, leading to the risk of over-medication and not promoting the highest function of the resident with the lowest dosage of the drug. The failure to follow up on the pharmacist's recommendation for a GDR constitutes a deficiency in the facility's drug regimen review process.
Failure to Provide Working Call Light System for Resident
Penalty
Summary
The facility failed to provide a working call light system for a resident, which could delay or prevent the resident from calling for assistance. The resident, an elderly female with significant medical conditions including nontraumatic subarachnoid hemorrhage, cognitive communication deficit, essential hypertension, hemiplegia, and hemiparesis, was observed multiple times without a call light in her room. Interviews with staff revealed that the call light had been removed because the resident accidentally activated it frequently. Despite this, staff acknowledged that every resident should have a call light within reach, even if they are unable to use it. The Maintenance Director and Interim DON were unaware of the missing call light until it was pointed out during the survey. The resident's care plan indicated the need for a call light to be within reach to ensure a safe environment and to prevent falls. However, observations and interviews confirmed that the resident did not have a call light, and staff had not taken appropriate steps to address this issue. The facility's policy on call light response, which mandates that each resident should have a call light to call for assistance, was not followed. This deficiency was identified through a combination of observations, interviews, and record reviews, highlighting a significant lapse in ensuring resident safety and timely assistance.
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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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