Windcrest Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Windcrest, Texas.
- Location
- 8800 Fourwinds Dr, Windcrest, Texas 78239
- CMS Provider Number
- 455533
- Inspections on file
- 33
- Latest survey
- August 14, 2025
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Windcrest Nursing And Rehabilitation during CMS and state inspections, most recent first.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
A male resident with a history of sexually inappropriate behavior was not consistently monitored or supervised, leading to two incidents of non-consensual sexual contact with a severely cognitively impaired female resident. Staff interviews revealed gaps in communication and training regarding required one-to-one supervision, and documentation errors contributed to the failure to implement effective preventative measures.
A resident with significant cardiac history experienced an unwitnessed fall and did not receive all required neurological assessments at scheduled intervals. The LPN on duty missed several neuro checks and did not inform the incoming nurse, who also failed to perform or document a neurological assessment or vital signs. The resident was later found deceased, and staff interviews confirmed that the facility's neuro check protocol was not followed or communicated as required.
A CNA assisted a resident with severe cognitive and physical impairments in dressing and standing, during which both lost balance and ended up on the floor. The CNA did not report the incident, believing it was not a fall, and the resident was not assessed for injuries until the next day when pain and a fractured arm were discovered. The facility failed to follow its policy requiring immediate reporting of suspected neglect and injury.
A resident with dementia and major depressive disorder, who exhibited sexually inappropriate behaviors, did not receive the 1:1 supervision intervention as outlined in their care plan. Staff interviews and record reviews showed inconsistencies in implementing and documenting this intervention, despite it being added to the care plan to address the resident's behaviors.
A resident with dementia, osteoporosis, and on hospice care did not receive prescribed Methadone on three occasions because the medication was not available at the time of administration. Nursing staff confirmed the missed doses and the need to request urgent refills, while documentation showed the facility was responsible for ensuring medication availability and administration as ordered.
The facility failed to implement policies to prevent abuse, neglect, and exploitation by not conducting required EMR/NAR checks for three newly hired agency CNAs. The facility relied on the agency's OIG checks, which did not include EMR/NAR, potentially placing residents at risk.
The facility failed to report several allegations of abuse, neglect, and injuries of unknown origin involving multiple residents to the appropriate authorities within the required timeframes. Incidents included unwitnessed injuries, neglect due to lack of clean mechanical lift slings, and complaints of verbal abuse and medication errors by staff. These failures violated the facility's prevention program and could place residents at risk for harm.
A resident with Alzheimer's and severe cognitive impairment was left in bed for long periods without necessary assistance for ADLs, including hydration, eating, and personal hygiene. Despite requiring extensive support, the resident was observed eating alone, spilling food, and lacking hydration, with no fall mats in place despite being a fall risk. Staff interviews and observations highlighted a lack of reporting and adherence to the care plan.
A resident with a history of a broken hip and stroke was not provided with necessary assistance to maintain continence, as his custom wheelchair did not fit into the bathroom. Despite being continent upon admission, the resident was forced to rely on adult briefs, which he found undignified. Staff were instructed not to assist him to the toilet due to safety concerns, leading to a deficiency in care.
The facility failed to ensure snacks were offered to all residents at bedtime, resulting in more than 14 hours between dinner and breakfast for some residents. Interviews revealed that only certain residents received labeled snacks, and staff were unaware of the requirement to offer snacks to all residents. This oversight placed residents at risk for unplanned weight loss and other health issues.
A resident's hard-shell helmet was found dirty with hair and stains, indicating a failure to maintain a clean and homelike environment. Interviews with staff revealed inconsistencies in cleaning procedures, with a CNA unsure of documentation and the DON unable to confirm the last cleaning. The facility's policy requires decontamination of equipment between residents.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their specific needs. One resident's care plan did not include interventions for her anxiety disorder, while another resident's plan lacked provisions for non-verbal pain assessment and communication tools. These oversights resulted in inadequate management of their conditions and unmet care needs.
A resident with hemiplegia, hemiparesis, and aphasia experienced unmanaged mouth pain due to the facility's failure to use communication boards and pain scales. Despite requiring extensive assistance with daily activities, the care plan lacked necessary tools for effective communication and pain management, leading to unmet personal care needs and inadequate pain relief.
A resident with severe cognitive impairment and at risk for pressure ulcers did not have a pressure-relieving cushion on her wheelchair, despite an active order. Observations and staff interviews revealed confusion about responsibility for ensuring the cushion was in place, with no specific guidance in the facility's policy.
A resident with dementia and a high risk for falls was left unsupervised in the dining room, despite her care plan requiring constant supervision. Observations showed no staff present, and interviews revealed staff were unaware of the supervision requirement. The facility's policy on person-centered care plans was not followed, putting the resident at risk of injury.
A resident with heart failure and diabetes was administered Midodrine despite having a systolic blood pressure above the prescribed threshold. The medication was given twice in July 2024, contrary to the physician's orders to hold it if SBP exceeded 130. The DON was unaware of the errors, and no staff reported the incidents, despite the facility's policy requiring adherence to prescribed medication administration practices.
A resident with dementia and other conditions experienced a significant decline, but the LTC facility failed to notify the family, believing hospice would do so. The DON and Administrator confirmed the facility's policy required direct notification to the family.
A resident in a LTC facility was allegedly abused by a healthcare aide, who was witnessed slapping the resident. The facility failed to immediately remove the aide from duty and did not report the incident within the required timeframe. Additionally, not all staff received proper training on abuse and neglect following the incident. The resident, who had dementia and was under hospice care, exhibited new behaviors of rejecting care, but did not receive psychiatric services.
A resident with a history of heart failure, hypertension, and high cholesterol exhibited stroke symptoms, including left-sided weakness and slurred speech, which were reported by therapy staff. However, the RN on duty dismissed the concerns, attributing symptoms to shoulder pain and administering Tylenol. The resident was not sent to the hospital until six hours after the initial symptoms were reported, due to a lack of communication and documentation among staff.
A staff member at an LTC facility misappropriated over $5,000 from a deceased resident's bank account by stealing their debit card. The theft was discovered through surveillance footage, and the staff member was charged with debit/credit card abuse. The facility failed to prevent this incident, despite having a policy in place to protect residents from such exploitation.
A facility failed to update a resident's care plan to reflect a doctor's order for honey consistency liquids, leading CNAs to administer nectar thick liquids instead. The resident, with conditions including dementia and dysphagia, was at risk of aspiration due to this oversight. Despite the kitchen providing the correct liquids during meals, the care plan's outdated information caused a discrepancy in care.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a severely cognitively impaired female resident from sexual abuse by another male resident with a history of sexually inappropriate behaviors. The male resident, who had diagnoses including dementia and major depressive disorder but was assessed as cognitively intact, had documented incidents of inappropriate sexual behavior, including masturbating in public and making sexual advances toward staff and other residents. Despite these documented behaviors, the facility did not consistently implement or communicate effective preventative measures, such as one-to-one supervision, to all staff members responsible for his care. On two separate occasions, the male resident engaged in non-consensual sexual contact with the female resident, who was unable to consent due to her cognitive impairment. The first incident involved kissing, and the second involved fondling in a common area. Staff interviews revealed a lack of awareness and training regarding the need for one-to-one supervision for the male resident, with several CNAs and new hires stating they were not informed about any such requirements or the resident's behavioral risks. Documentation errors were also noted, including backdating of care plan interventions and inconsistent communication of behavioral interventions across shifts and departments. The facility's records showed that previous incidents of sexually inappropriate behavior by the male resident were discussed in meetings but did not always result in clear, actionable interventions or consistent staff oversight. There was no established process to ensure that information about behavioral risks and required interventions was reliably passed on between shifts or to all relevant staff. As a result, the male resident was observed unsupervised in his room and in common areas, and staff failed to prevent further incidents of abuse against the cognitively impaired female resident.
Removal Plan
- The Administrator/designee will place the male resident involved on 1:1 supervision immediately to ensure no sexually inappropriate behavior occurs. This 1:1 supervision will be provided until alternate placement for resident #1 is secured or he is cleared by the medical director or psychiatrist.
- Resident #2 was evaluated by the psychiatric nurse practitioner. The psychiatric nurse practitioner did not note a deviation of the resident's baseline behavior or mood. Resident #2 has an order for behavior monitoring that occurs every shift and is ongoing to monitor for mood changes.
- The Administrator/Designee will interview all team members to determine if team members have knowledge of any inappropriate sexual behavior of male residents that may have occurred and has not been reported. If any are identified, an immediate assessment and a self-report will be completed.
- The Administrator and Director of Nursing will be educated by the Regional Director of Clinical Services on reportable sexually inappropriate behavior, including: residents must have the capacity to make decisions to give consent for sexual activity; sexual activity without consent or cognitive ability to give consent is a reportable event; definitions of abuse and sexual abuse; monitoring for sexually aggressive behavior; and placing any resident displaying sexually inappropriate behaviors involving non-cognitive residents on 1:1 supervision until evaluated and deemed safe.
- DON/Designee will provide training for all team members on reportable sexual inappropriate behavior, including: education on male residents' 1:1 status and sexually inappropriate behavior; sexual activity without consent or cognitive ability to give consent is a reportable event; definitions of abuse and sexual abuse; monitoring for sexually aggressive behavior; reporting all sexually inappropriate behavior to the Admin/DON immediately and intervening to prevent any injury; training to be provided upon hire, annually, and as needed; all staff to be educated before their next scheduled shift.
- Education was provided to all staff regarding residents who do not have the cognitive ability to give consent.
- The Administrator/Designee conducted safe surveys with all cognitively intact residents residing on the A and B wings, asking about inappropriate touching or unwelcome advances and feelings of safety.
- DON/Designee completed full skin assessments for non-cognitively intact residents residing on A and B wings to check for evidence of sexually inappropriate behavior or signs of sexual abuse.
- DON/Designee will monitor process compliance and understanding daily during the morning clinical process and room rounding observations.
- An Ad Hoc QAPI committee meeting was held with the Medical Director regarding the current IJ and plan of correction.
- Results of in-servicing and interviews will be reviewed during the monthly QA meeting.
Failure to Complete and Communicate Required Neurological Assessments After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to provide neurological assessments in accordance with professional standards of practice for a resident following an unwitnessed fall. The resident, who had a history of atrial fibrillation, atherosclerotic heart disease, hypertension, and a recently implanted pacemaker, was found on the floor in her bedroom early in the morning. Initial neurological checks were performed every 15 minutes as required, but subsequent scheduled assessments at 6:45 AM and 7:15 AM were not completed or documented by the nurse on duty. The nurse also failed to communicate the missed assessments to the oncoming nurse during the shift change. The oncoming nurse, who arrived late for her shift, did not perform a neurological assessment when she first checked on the resident, nor did she document the resident's vital signs. Shortly after, the resident was found unresponsive and was pronounced deceased. Documentation and interviews confirmed that the required neuro checks were not performed or recorded as per the facility's protocol, and there was a lack of clear communication between nursing staff regarding the resident's ongoing assessment needs. Interviews with staff revealed that all were aware of the facility's neuro check protocol, which required immediate initiation of neurological assessments after any unwitnessed fall or head injury, with specific intervals for monitoring and documentation. Despite this, the protocol was not followed in this instance, resulting in a lapse in the standard of care provided to the resident.
Failure to Timely Report and Investigate Resident Fall Resulting in Injury
Penalty
Summary
The facility failed to ensure that an alleged violation involving neglect was reported immediately, but not later than 24 hours, to the administrator and appropriate authorities as required by policy and regulation. A certified nursing assistant (CNA) assisted a resident with dementia, muscle weakness, and ataxic gait in dressing and attempted to help her stand from the bedside. During this process, both the CNA and the resident lost their balance and ended up on the floor. The CNA did not report this incident to the nurse, the Director of Nursing (DON), or the Administrator. The resident, who was dependent on staff for dressing and transfers due to severe cognitive and physical impairments, was not assessed for injuries following the incident because the CNA did not believe the event constituted a fall and therefore did not report it. The nurse on duty during the shift was unaware of the incident and did not perform an assessment. The following day, another CNA noticed the resident had shoulder pain during ADL care, and a nurse subsequently assessed the resident, discovering limited range of motion and pain in the left arm. A mobile x-ray revealed a fractured arm, and the resident was sent to the hospital for further evaluation and treatment. The facility's policy requires immediate reporting of suspected abuse, neglect, or injury of unknown source to the administrator and appropriate authorities. The incident was not reported until the injury was discovered and investigated by the administrator the following day. The delay in reporting and assessment resulted from the CNA's misunderstanding of what constitutes a fall and the failure to follow established reporting procedures.
Failure to Implement Person-Centered Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan for a resident with a history of dementia and major depressive disorder, who exhibited sexually inappropriate behaviors. The resident's care plan identified issues such as entering other residents' rooms, masturbating in inappropriate settings, making sexually inappropriate comments, and attempting to touch female staff and residents. The care plan included an intervention for 1:1 supervision when the resident was out of bed and room, with the goal of reducing these behaviors. However, interviews and record reviews revealed that this intervention was not consistently implemented as intended. Staff interviews indicated that while the inappropriate behaviors were discussed in morning meetings and interventions were added to the care plan, there were inconsistencies in the documentation and implementation of the 1:1 supervision intervention. The intervention was backdated in the care plan, and staff acknowledged the importance of following interventions as part of the resident's care plan. The facility's policy required the care plan to describe services to maintain the resident's highest practicable well-being, but the failure to implement the 1:1 supervision intervention as planned resulted in the deficiency.
Missed Methadone Doses Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the accurate acquiring, receiving, dispensing, and administering of Methadone as ordered. Specifically, a resident with multiple diagnoses including dementia, osteoporosis, osteoarthritis, and who was on hospice care, did not receive her prescribed Methadone oral tablet on three occasions: once in July 2024 and twice in February 2025. Medication Administration Records (MAR) showed blank entries for the missed doses, and progress notes confirmed that at least one dose was not administered because the medication was not available. The nurse requested a STAT refill from hospice, and the resident was assessed for pain, which was documented as 0/10 at the time of the missed dose. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the facility was responsible for ensuring medication availability and administration as ordered. The process for obtaining urgent medication refills involved notifying hospice or the charge nurse, but in this instance, the medication was not on hand when needed. The facility's policy outlined procedures for refill and urgent orders, but the failure to have Methadone available resulted in missed doses for the resident.
Failure to Conduct Proper Background Checks for Agency CNAs
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified in the files of three newly hired CNAs (A, B, and C) who were agency staff. The facility did not conduct the required EMR/NAR checks for these CNAs before they began working on the floor. Although the agency completed OIG background checks, the facility did not verify these checks included EMR/NAR, which is a requirement according to their policy. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention, dated April 2021, mandates conducting employee background checks and not employing individuals with findings in the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of their property. However, the facility's administrator admitted that they did not check the CNAs' background for EMR/NAR, relying instead on the agency's OIG checks. This oversight could place residents at risk of abuse, neglect, and exploitation.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the appropriate authorities within the required timeframes. Specifically, the Administrator, Director of Nursing (DON), and various Licensed Vocational Nurses (LVNs) did not report several incidents involving Resident #15, including unwitnessed injuries and allegations of neglect. On multiple occasions, Resident #15 was found with injuries such as abrasions and bruises, and there were complaints from the resident's representative about neglect due to a lack of clean mechanical lift slings. Despite these incidents, the facility did not report them to the state agency as required. Additionally, the facility failed to report allegations of abuse and neglect involving Residents #140 and #141. Resident #140 complained about a rude overnight nurse, lack of an arm sling, and issues with pain medication, while Resident #141 reported verbal abuse and negligence in pain medication administration by the overnight nurse. These grievances were documented but not reported to the state agency, as the DON and Administrator did not consider them reportable incidents. The facility's failure to report these incidents is a violation of their Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, which mandates the identification, investigation, and reporting of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property within the required timeframes. The lack of timely reporting could place residents at risk for harm by abuse or neglect, as the facility did not adhere to established procedures for protecting residents from such incidents.
Failure to Provide Necessary ADL Support for Resident
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to perform activities of daily living (ADLs) independently. The resident, who had Alzheimer's disease, anxiety disorder, and weakness, was observed left in bed for extended periods without assistance. On multiple occasions, the resident was found without hydration at his bedside and with remnants of meals on his gown and bed linens, indicating a lack of assistance with eating and personal hygiene. The resident's care plan required extensive assistance with dressing, personal hygiene, toileting, and transferring, as well as limited assistance with eating. Despite these requirements, the resident was observed eating alone and spilling food, and there was no evidence of staff providing the necessary support. Additionally, the resident was identified as a fall risk, yet no fall mats were placed beside the bed, and the resident's refusal to get out of bed was not reported by the CNA responsible for his care. Interviews with staff and observations revealed that the resident often refused to get out of bed and was left without water, relying on a roommate's representative for hydration. The facility's policy stated that residents should receive care to maintain or improve their ADLs, but the resident's needs were not adequately met, as evidenced by the lack of hydration, assistance with meals, and personal hygiene support.
Failure to Support Resident's Continence and Bathroom Use
Penalty
Summary
The facility failed to ensure that a resident who was continent of bladder and bowel upon admission received the necessary services and assistance to maintain continence. This deficiency was identified for one resident who was reviewed for their right to use the bathroom. The resident, who had a history of a broken right hip and right-side body weakness following a stroke, was assessed with moderate cognitive impairment but had adequate hearing and speech. Despite being able to make himself understood and understand others, the resident was not provided with a toileting program and was instead assessed as frequently incontinent. The resident expressed grievances about being unable to use the bathroom due to the size of his custom wheelchair, which did not fit into the bathroom. The resident felt that he was being forced to soil himself and rely on adult briefs, which he found undignified. Despite his requests for assistance to use the toilet, staff were instructed not to take him to the bathroom, citing safety concerns. The resident's care plan indicated that he required extensive assistance for toileting and transfers, but no effective solution was implemented to address his needs. Interviews with staff, including the Director of Rehabilitation and the Physical Therapist, confirmed that the resident's larger wheelchair was necessary after his hip fracture, but it could not fit into the bathroom. The facility's maintenance director confirmed that all resident bathrooms were of the same size, which was inadequate for the resident's needs. Despite the resident's grievances and the facility's policy on supporting activities of daily living, the resident's right to use the bathroom was not upheld, leading to a deficiency in care.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime. This deficiency was identified for 4 out of 7 residents reviewed for meal frequency. The facility did not offer snacks at bedtime as required, which could affect all residents receiving meals from the facility's kitchen. The lack of snacks placed residents at risk for unplanned weight loss, side effects from medication taken without food, and diminished quality of life. Interviews and record reviews revealed that the facility's snack distribution process was inadequate. The facility's snack list only included residents with specific orders, and there was no general list for all residents. Staff interviews indicated that snacks were labeled and distributed to certain residents, but not all residents were informed or offered snacks. The Director of Nursing and the Administrator were unaware that snacks had to be offered to all residents, and the facility's policy on snacks was incorrect. The facility's failure to provide snacks as required was a significant oversight in their care practices.
Failure to Maintain Cleanliness of Resident Equipment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in the maintenance of the resident's hard-shell helmet. The helmet, which was observed on the nurse's station desk, was found to have hair, brown and black particulate, and brown stains on the inside where it sat atop the resident's head. This observation was made during a survey, and the resident was unable to respond during an attempted interview. Interviews with facility staff revealed a lack of clarity and consistency in the cleaning procedures for resident equipment. A CNA mentioned that they clean equipment when it appears dirty and believed that overnight staff were responsible for regular cleaning, but was unsure where such cleanings would be documented. The DON stated that resident helmets should ideally be cleaned daily, but could not confirm when the helmet was last cleaned. The facility's policy on cleaning and disinfection of resident-care items was reviewed, indicating that reusable equipment should be decontaminated between residents according to manufacturers' instructions.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in their care. Resident #60, a female with severe cognitive impairment and diagnoses including generalized anxiety disorder, did not have her anxiety disorder adequately addressed in her care plan. The care plan only mentioned the use of antidepressant medication related to depression and poor appetite, without any specific interventions for managing her anxiety disorder. This oversight could potentially impact the effectiveness of her treatment and overall well-being. Resident #1, who has a history of hemiplegia, cerebrovascular disease, and aphasia, did not have a care plan that addressed the use of a non-verbal pain scale or communication board. Despite her communication challenges, staff did not consistently use non-verbal pain assessment tools, leading to inadequate pain management. Observations revealed that Resident #1 experienced mouth pain, which was not promptly addressed due to communication barriers. Interviews with staff indicated a lack of awareness and documentation regarding her pain and personal care needs, such as bathing and oral hygiene. The report highlights that staff were not fully utilizing available communication tools to understand and meet Resident #1's needs. Additionally, there was a lack of documentation and follow-up on her dental issues, which contributed to her ongoing discomfort. The facility's failure to incorporate these critical aspects into the residents' care plans resulted in deficiencies that could compromise their physical, mental, and psychosocial well-being.
Failure to Use Communication Aids and Pain Assessment Tools
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable due to clinical conditions. Specifically, the facility did not use a communication board or a facial pain scale for a resident with hemiplegia, hemiparesis, and aphasia, which are conditions that affect communication and mobility. This oversight led to the resident experiencing unmanaged mouth pain and a lack of proper communication regarding her needs. The resident, who was admitted with multiple diagnoses including cerebrovascular disease, dementia, and aphasia, required extensive assistance with activities of daily living such as bathing, dressing, and personal hygiene. Despite these needs, the care plan did not include the use of non-verbal pain scales or communication boards, which are crucial for residents with communication difficulties. Observations revealed that the resident was in pain and had difficulty communicating this to the staff, who did not consistently use available tools to assess her pain levels. Interviews with staff indicated a lack of awareness and use of communication aids, leading to inadequate pain management and unmet personal care needs. The resident expressed dissatisfaction with the staff's understanding of her pain and needs, and there were inconsistencies in the documentation of her care, such as bathing and oral hygiene. The facility's failure to implement appropriate communication strategies and pain assessment tools resulted in a deficiency in maintaining the resident's dignity and quality of life.
Failure to Provide Pressure-Relieving Cushion for Resident
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing and prevent new ulcers from developing. Specifically, the facility did not equip Resident #53's wheelchair with a pressure-relieving cushion, as ordered. The resident, an elderly woman with severe cognitive impairment and at risk for pressure ulcers, was observed without the cushion on multiple occasions. Despite having an active order for the cushion since March, it was not present during observations in late June. Interviews with staff revealed a lack of clarity regarding responsibility for ensuring the cushion was in place. The Housekeeping Manager believed it was the responsibility of physical therapy, while the LVN was unsure of the cushion's whereabouts. The ADON and DON both expressed that it was the responsibility of all staff to ensure residents had their necessary equipment, but this expectation was not met. The facility's policy on pressure ulcer care did not provide specific guidance on ensuring pressure-reducing devices were in place, contributing to the oversight.
Failure to Supervise High-Risk Resident in Dining Room
Penalty
Summary
The facility failed to provide adequate supervision for a resident, identified as Resident #39, who was at high risk for falls due to multiple health conditions including dementia, dysphagia following a stroke, and diabetes. The resident's care plan specifically required constant supervision while in the dining room due to her high fall risk and other behavioral issues. However, observations on two separate occasions revealed that the resident was left unsupervised in the dining room, with no staff within ear or eyeshot, contrary to the care plan's directives. Interviews with staff, including an LVN and the DON, highlighted a lack of awareness and adherence to the supervision requirements outlined in the resident's care plan. The LVN was unaware of the need for constant supervision, while the DON acknowledged that staff should supervise the resident at all times in the dining room to prevent potential injuries from falls. The facility's policy on comprehensive, person-centered care plans was not effectively implemented, as evidenced by the lack of supervision for Resident #39, placing her at risk of injury.
Medication Administration Error for Midodrine
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of Midodrine. The resident, a male with a history of heart failure and diabetes, was prescribed Midodrine to be administered via PEG-Tube twice daily for hypotension, with instructions to hold the medication if the systolic blood pressure (SBP) exceeded 130. However, the medication was administered on two occasions in July 2024 when the resident's SBP was 132, which was above the threshold specified in the physician's orders. Interviews and record reviews revealed that the Director of Nursing (DON) was unaware of these medication errors, and no staff had reported the incidents. The facility's policy on medication administration, dated December 2021, emphasized that medications should be administered as prescribed and in accordance with good nursing practices. Despite this policy, the errors occurred, and the DON confirmed that there was no notification of issues with the parameters set for the medication administration.
Failure to Notify Resident's Family of Condition Change
Penalty
Summary
The facility failed to immediately notify a resident's representative when there was a significant change in the resident's condition. Specifically, a resident with diagnoses including unspecified dementia, schizoaffective disorder, and high blood pressure, who was receiving hospice services, experienced a significant decline in condition. On the day of the incident, the resident was found to be very lethargic with critically low oxygen saturation levels. Although the facility contacted the hospice service, they did not notify the resident's family member, who was the responsible party. Interviews revealed that the Licensed Vocational Nurse (LVN) involved believed it was the hospice's responsibility to inform the family, which led to the oversight. The Director of Nursing (DON) and the Administrator both acknowledged that the facility's policy required the nursing staff to notify the resident's family directly, regardless of hospice involvement. The failure to notify the family was recognized as a deficiency, as it could cause emotional distress to the family if they were unaware of the resident's condition change.
Failure to Protect Resident from Abuse and Timely Report Incident
Penalty
Summary
The facility failed to protect a resident from abuse, neglect, and exploitation, as evidenced by an incident involving a resident who was allegedly abused by a healthcare aide. The incident was witnessed by a CNA who reported seeing the aide slap the resident on the shoulder twice. The resident, who was described as small, fragile, and nonverbal, exhibited signs of shock and flinching during the incident. The facility did not ensure that the alleged perpetrator was removed from duty immediately, allowing the aide to continue working and have access to residents. The facility also failed to report the abuse incident within the required two-hour timeframe, as mandated by federal regulations. The administrator was informed of the incident the following morning but did not report it promptly. Additionally, the facility did not ensure that all staff members were properly educated on abuse, neglect, and exploitation following the incident, with missing signatures on in-service training records. The resident involved in the incident had a history of dementia and major depressive disorder and was under hospice care. Despite the resident's nonverbal status, the facility did not provide psychiatric services after the incident, even though the resident exhibited new behaviors of rejecting care. The medical doctor was not informed of these new behaviors, which could have warranted further assessment and intervention.
Delayed Response to Stroke Symptoms in Resident
Penalty
Summary
The facility failed to provide timely treatment and care for a resident who exhibited signs and symptoms of a stroke. The resident, who had a history of heart failure, hypertension, and high cholesterol, was not sent to the hospital for evaluation until approximately six hours after a change in condition was reported. Initially, a Certified Occupational Therapy Assistant (COTA) observed the resident's inability to use his left side and reported it to a Registered Nurse (RN), who dismissed the concerns. The Physical Therapy Assistant (PTA) also noted the resident's slurred speech and left-sided weakness and reported these findings to the Director of Rehabilitation (DOR). Despite multiple reports from therapy staff, the RN on duty did not document any findings or escalate the issue appropriately. The RN believed the resident was fine and attributed the symptoms to shoulder pain, administering Tylenol instead of recognizing potential stroke symptoms. The DOR later assessed the resident and reported the changes to the oncoming nurse, who then contacted the Nurse Practitioner (NP) and received orders to send the resident to the emergency room. However, the resident was not transported until three hours after this assessment, and six hours after the initial symptoms were reported. The delay in recognizing and responding to the resident's stroke symptoms was attributed to a lack of communication and documentation among staff, as well as a failure to follow established protocols for emergency situations. The RN on duty at the time of the incident was unfamiliar with the residents and did not receive adequate information during the shift change. The facility's Director of Nursing (DON) later stated that assessments should be documented immediately, and changes in condition should be reported promptly to the primary care provider.
Misappropriation of Resident's Property by Staff Member
Penalty
Summary
The facility failed to protect a resident from misappropriation and exploitation of their property. A staff member, identified as MA G, stole a debit card belonging to a resident who had passed away, and subsequently withdrew over $5,000 from the resident's bank account. The theft was discovered when a police officer arrived at the facility to confirm the identity of the staff member from surveillance footage. The administrator confirmed the individual in the footage was MA G, who was then charged with debit/credit card abuse to an elderly person. Further investigation revealed that the Assistant Director of Nursing (ADON) was aware that the resident kept an address book containing sensitive financial information, which went missing after MA G provided post-mortem care to the resident. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not effectively implemented, as the incident was not prevented. Attempts to contact the resident's family were unsuccessful, and the facility's failure to prevent this misappropriation placed residents at risk of similar incidents.
Failure to Update Care Plan for Liquid Consistency
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team to reflect the current condition, specifically regarding the resident's need for honey consistency liquids instead of nectar thick liquids. The resident, who was admitted with diagnoses including dementia, dysphagia, and cognitive communication deficit, had a doctor's order for honey consistency liquids since August 2022. However, the care plan still indicated nectar thick liquids, leading to the CNAs administering the incorrect liquid consistency. Interviews and record reviews revealed that the CNAs were following outdated directives from the care plan, which had not been revised to reflect the doctor's updated order. The Speech Therapist highlighted the risk of aspiration and potential severe health consequences if the resident received the incorrect liquid consistency. Despite the kitchen providing the correct honey thickened liquids during meals, the care plan's outdated information led to a discrepancy in care, as CNAs were tasked with providing nectar thick liquids based on the care plan's instructions.
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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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