Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winfield Rehab & Nursing during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week, with no RN present for several days identified in staffing and time punch records. The Regional Nurse Consultant said she was covering RN duties because there was no DON in the facility at the time, but she was unsure why coverage was missed on the identified dates. The Administrator said she was not aware that an RN was absent for the required 8 hours on those days.
Inaccurate PBJ RN Staffing Submission: The facility failed to submit complete and accurate CMS PBJ staffing data for RN hours, with the PBJ report showing no RN hours on multiple days despite time punch records showing RN coverage on nearly all of those dates. The Administrator said she completed the RN hour spreadsheet and sent it to corporate for PBJ entry, but was unaware the hours were reported inaccurately; the facility policy stated it is responsible for timely and accurate PBJ submission.
Dish Machine Sanitizer Level Below Required Range: The dish machine in the kitchen was found with a chlorine level of 10 ppm after the final rinse cycle, below the facility’s required 50-100 ppm range. The DM stated the machine should have at least 50-100 ppm of hypochlorite and noted that improper sanitizer levels could affect whether dishes were cleaned and sanitized properly. A later check found the machine at 50 ppm, and the facility policy for ware washing required chlorine sanitizer at 50-100 ppm.
Gas Stove Burners Not Lighting Properly: Two of six gas stove burners did not light completely when turned on, with only half of each burner lit. The DM said the stove had been that way for 2 years and kitchen staff did not use those burners. The Administrator and Maintenance Supervisor gave differing accounts of when the issue was reported, and no stove policy was provided by survey exit.
Expired insulin pens were found on a 300-hall med cart, including an insulin pen with no open date despite pharmacy directions to discard it 28 days after opening. A resident with type 2 DM had orders for insulin therapy, and the DON stated she was unaware of the expired insulin, removed it, and placed new pens in the cart. Facility policy required injectable meds to be stored and labeled per manufacturer or pharmacy directions, and the Administrator said the DON was responsible for proper medication storage.
Unlabeled insulin was found in a nurse med cart, with no open date documented on the Lantus Solostar pen even though the pharmacy directions required discard 28 days after opening. The resident involved had type 2 DM and orders for both sliding-scale insulin aspart and daily insulin glargine. The DON said she was unaware the cart contained unlabeled insulin, and the Administrator stated the DON was responsible for ensuring meds were labeled and stored as required.
Expired Food Found in Resident Refrigerator: A resident’s personal refrigerator contained a bottle of Miracle Whip that had expired, and it remained there during repeat observation. The resident said she had not used it in a long time and did not know it was expired. The resident had CHF, COPD, type 2 DM, and moderate cognitive impairment. Staff gave conflicting accounts about who checked personal refrigerators and whether expired foods were reviewed during daily rounds.
A resident with CHF, COPD, type 2 DM, and spine fusion had a dirty towel with a brown substance left on the bathroom floor across multiple observations. The resident was incontinent and needed assistance with hygiene and toileting. CNA E later found the towel still on the floor and removed it, while the DON and Administrator stated soiled linens should be bagged and placed in the soiled linen area, not left on the floor.
The facility failed to incorporate PASARR recommendations into assessment, care planning, and transition of care for two residents with PASARR-positive status. One resident with ID had a PCSP showing Specialized OT as a new service, but no NFSS form was submitted in SIMPLE after the IDT meeting. Another resident with ID and DD had an annual PCSP requesting Specialized OT, but staff could not locate a timely NFSS submission and the form that was entered was returned due to signature issues and not resubmitted. Staff interviews showed confusion about who was responsible for the portal submission and the required timeframe.
A resident with dementia and another resident with Alzheimer’s disease were observed without needed ADL care. One resident had a thick, black substance under his fingernails across multiple observations despite care plans calling for grooming and nail care, and the other remained in food-soiled shirt and pants through meals and while in bed. Staff interviews confirmed that residents who could not manage these tasks themselves should have received the care when needed.
A resident with multiple chronic conditions was left with medications in her room unsupervised, resulting in pills being found on the floor. Staff interviews and facility policy confirmed that medications should be administered under direct observation or securely stored, but this was not followed, leading to a lapse in pharmaceutical services.
A resident with severe cognitive impairment and Alzheimer's Disease was physically restrained by a CNA during incontinence care, despite care plan instructions to stop and return later if the resident became agitated. The CNA held the resident's hands to his chest and restrained him on the bed after the resident became combative when awakened. The incident was witnessed by another CNA, reported to nursing staff, and confirmed by video evidence.
A resident with severe cognitive impairment and no prior history of wandering exhibited new exit-seeking behaviors that were documented but not acted upon by staff. The resident was able to leave the facility unsupervised by following visitors out, and staff only became aware of the elopement after being contacted by a neighboring facility. The lack of timely intervention and communication among staff led to this deficiency.
A resident with severe cognitive impairment and total dependence for transfers experienced a fall during a mechanical lift transfer performed by a single NA, despite the care plan and policy requiring two staff. The incident was not reported to the state agency within the required timeframe, as mandated by facility policy for potential neglect, even though the resident was assessed and found to have no injuries.
A resident with severe cognitive impairment and total dependence on staff for transfers was dropped during a mechanical lift transfer when a nursing assistant attempted the procedure alone, contrary to policy. The incident was not reported to the state agency within the required timeframe, despite facility policy and state regulations mandating such reporting for alleged neglect, regardless of injury.
A resident with severe cognitive impairment and total dependence for transfers was moved using a mechanical lift by a single NA, despite care plan and policy requiring two staff. The NA used mismatched sling hooks and, during the transfer, the resident began to slide out of the sling. The NA attempted to prevent a fall by grabbing the resident's shirt and sling, lowering her to the floor. The resident was assessed by an LVN and found to have no injuries or change in condition. The NA admitted to acting alone despite knowing the policy.
A resident with severe cognitive impairment fell during a mechanical lift transfer due to improper use of the lift and inadequate supervision by staff. The incident resulted in a subdural hematoma and shoulder separation. Observations revealed that the lift sling was faded and lacked a manufacturer's tag, and staff did not lock the lift's legs during the transfer. The facility did not report the incident to the state agency, citing it as an accident.
The facility failed to ensure accessible call light strings in the bathrooms of three residents, with strings either tied in knots or wrapped around grab bars, making them unreachable. Residents had various medical conditions, including intellectual disabilities and fall risks. Staff interviews revealed a lack of responsibility for checking call light strings, and the facility's policy was not consistently followed.
The facility failed to ensure proper training for the Interim DON, Dietary Manager, and a CNA, leading to deficiencies in required training on HIV, dementia, and restraint reduction. The HR personnel was unaware of the need for training completion before resident care, and the Administrator acknowledged the oversight in ensuring staff received necessary training.
The facility failed to ensure that QAPI training was completed for key staff members, including the Interim DON, Dietary Manager, and a CNA, during their orientation and annual training. The HR personnel was unaware of the training requirements, leading to a lack of necessary training before staff began resident care. The Administrator acknowledged the oversight and the facility's policy mandates training completion before independent service provision.
The facility failed to provide mandatory infection prevention and control training to the Interim DON, Dietary Manager, and a CNA, potentially placing residents at risk. The Interim DON and CNA did not receive training upon hire, and the Dietary Manager did not receive annual training. Interviews revealed gaps in the training process, with the HR representative unaware of the requirement for training completion before resident care and the Administrator acknowledging responsibility for ensuring staff training.
The facility failed to ensure that the Interim DON, Dietary Manager, and a CNA received required compliance and ethics training. The Interim DON and CNA did not receive training upon hire, while the Dietary Manager missed annual training. The HR representative was unaware of the training requirements, and the Administrator confirmed responsibility for ensuring training completion.
The facility failed to provide mandatory behavioral health training for an Interim DON and a CNA upon hire, as required by policy. The HR personnel was unaware of the training requirements, and the administrator confirmed that staff were expected to complete training online. This deficiency could risk residents' well-being due to untrained staff.
The facility failed to maintain proper infection control practices, as staff members did not adhere to hand hygiene protocols during meal and medication passes. CNA F did not sanitize hands between resident interactions, while Medication Aide H used an aerosol spray instead of the approved sanitizer. Medication Aide M also neglected hand hygiene and used improperly sanitized equipment. Additionally, reusable equipment was not adequately cleaned, posing a risk of infection transmission.
A resident with intellectual disabilities fell from a mechanical lift during a transfer, resulting in a subdural hematoma and shoulder separation. The facility did not report the incident to the state agency within the required timeframe, despite the serious injuries sustained. Staff interviews indicated uncertainty about how the strap came off, and the incident was deemed an accident by the facility's administration.
A resident with a history of heart disease and COPD was found to have a lighter in his possession, contrary to the facility's smoking policy. Despite the care plan requiring smoking materials to be kept at the nurse's station, the resident kept a lighter due to past issues with staff availability during smoking times. The facility's administrator acknowledged the oversight, which could lead to an unsafe smoking environment.
The facility failed to provide required effective communication training to two new staff members, an Interim DON and a CNA, during their orientation. This oversight was identified through employee file reviews, revealing that the necessary training was not completed before they began resident care. The HR representative and Administrator acknowledged the lapse, with the HR representative unaware of the requirement for training completion prior to starting resident care.
The facility failed to ensure that the Interim DON and a CNA completed training on resident rights and facility responsibilities during orientation. This deficiency was identified through interviews and record reviews, revealing that these staff members had not completed the required training before starting resident care. The HR representative admitted to being unaware of the training requirements, while the Administrator confirmed the expectation for staff to complete training prior to employment.
A CNA at the facility did not complete required training in Abuse, Neglect, and Exploitation (ANE) and dementia management during orientation. This was discovered through interviews and record reviews, revealing that the CNA, hired in March 2024, had not fulfilled these training requirements. The Interim DON and HR acknowledged the oversight, with HR planning to implement a checklist to ensure future compliance. The Administrator confirmed the expectation for staff to complete training videos, as per facility policy.
The facility failed to ensure that an Interim DON and a CNA received mandatory training on Abuse, Neglect, and Exploitation, as well as dementia management during their orientation. This oversight was discovered through interviews and record reviews, revealing that these staff members had not completed the necessary training before starting resident care. The HR representative was unaware of the requirement for training completion prior to resident care, and the Administrator confirmed the responsibility to ensure training was completed before employment.
The facility failed to protect residents from abuse and neglect, with incidents involving verbal abuse by a housekeeper and multiple resident-to-resident physical altercations. There was inadequate documentation and monitoring of these incidents, particularly for residents with cognitive impairments. The facility's lack of supervision and failure to provide consistent behavioral health interventions contributed to the deficiencies.
The facility failed to implement effective abuse prevention policies, resulting in multiple incidents of abuse involving both staff and residents. A resident was verbally abused by a housekeeper, and several resident-to-resident physical altercations occurred without adequate documentation or intervention. The facility's lack of comprehensive monitoring and intervention strategies was evident in the insufficient documentation and failure to provide requested behavior monitoring reports.
The facility failed to prevent and manage pressure ulcers for three residents, leading to untreated wounds and inadequate use of preventative equipment. One resident had multiple untreated pressure wounds, another had an arterial wound on the heel that was not identified or treated, and a third resident was found on a deflated low air loss mattress, compromising pressure relief. The facility did not conduct regular skin assessments or follow wound care recommendations.
A resident experienced two incidents of falling out of a wheelchair during transport in a facility van due to inadequate supervision and failure to use safety harnesses. The transport driver did not use the safety harnesses as the resident refused, and the facility's maintenance supervisor was not trained on van safety. Worn straps in the van contributed to the incidents, and the facility's transportation policy requiring seat belt use was not followed.
The facility failed to maintain a clean and safe environment in four resident shower rooms, with mold observed on tiles and baseboards. The 400-hall shower room was out of order and cluttered, while the 100-hall room had a strong vinegar smell. Staff confirmed the presence of mold and the need for deep cleaning. The Housekeeping Supervisor and Administrator acknowledged the issue, but no cleaning policy was provided.
The facility failed to ensure six nurse aides were certified within four months of hire, placing residents at risk. Observations showed that non-certified aides, like one who had been working for nine months, were providing care independently without proper certification. Interviews revealed a lack of oversight and awareness among facility staff regarding the certification status of these aides, contradicting facility policy.
A facility failed to report an alleged abuse incident involving two residents within the required timeframe. A resident with severe cognitive impairment was found in another resident's room, engaging in inappropriate behavior. Despite being informed, the Administrator did not report the incident to the state agency, citing a lack of emotional distress in the affected resident. Interviews with staff confirmed the incident was documented, but the necessary reporting steps were not taken.
A resident with a history of hemiplegia and other conditions did not have a bowel movement for 14 days, leading to severe health issues and eventual death. The facility failed to notify the physician of the resident's condition, and staff did not effectively monitor or document bowel movements. Communication breakdowns and internet outages contributed to the lack of timely medical intervention.
A resident with a history of hemiplegia and other conditions did not have a bowel movement for 14 days, leading to a severe decline in health. Despite having a care plan in place, the facility failed to monitor and document the resident's bowel movements, resulting in hospitalization and eventual death due to sepsis and fecal impaction. Staff interviews revealed a lack of communication and adherence to the facility's policy on bowel monitoring.
RN Coverage Not Maintained Daily
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 2 of 3 months reviewed, specifically in July 2025 and August 2025. Record review of the PBJ Staffing Data Report for fiscal year Quarter 4 2025 showed no RN hours on multiple dates in July, August, and September 2025, and the facility time punch report dated 7/01/2025 to 9/30/2025 indicated the facility had RN coverage on all dates except 7/26/2025, 7/27/2025, 8/02/2025, and 8/03/2025. During an interview on 12/10/2025, the Regional Nurse Consultant said she was the RN coverage from July 2025 to September 2025 because there was no DON in the facility at that time and she was responsible for staffing. She stated she was unsure why there was no RN coverage on the four dates identified. The Administrator said the DON was responsible for staffing, that the DON was covered by the regional nurse during that period, and that she was not aware there were days when an RN was not in the facility for the required 8 hours.
Inaccurate PBJ RN Staffing Submission
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for FY 2025 Q4, including RN hours and agency/contract staff hours, based on payroll and other verifiable and auditable data in the required uniform format. The PBJ Staffing Data Report for July 1 through September 30, 2025 showed no RN hours reported for multiple dates, including numerous days in July, August, and September, even though the facility time punch report showed RN coverage in the facility on all dates except 7/26/2025, 7/27/2025, 8/02/2025, and 8/03/2025. During interview on 12/10/2025, the Administrator stated she completed the spreadsheet for RN hours worked and submitted it to an offsite corporate office person to input into PBJ, and she was not aware that the hours had been inaccurately reported. The record also included a facility policy stating that the facility is responsible for submitting timely and accurate staffing data through the CMS PBJ system.
Dish Machine Sanitizer Level Below Required Range
Penalty
Summary
The facility failed to ensure the dish machine was storing, preparing, and distributing food under sanitary conditions in the kitchen. During an observation and interview on 12/8/2025 at 9:41 AM, the dish machine was checked by the DM and the hypochlorite (chlorine) level after the final rinse cycle registered at 10 ppm, below the facility’s stated minimum of 50-100 ppm. The DM stated the dish machine should have at least 50-100 ppm of hypochlorite and said the dishes might not be clean enough if the machine did not have the proper amount of sanitization chemicals. A follow-up observation on 12/8/2025 at 4:34 PM found the dish machine testing at 50 ppm, meeting regulation and policy. During an interview on 12/10/2025 at 2:30 PM, the Administrator stated the technician repaired the dish machine and increased the sanitizer for the machine. Record review of the service report showed a tech serviced the dish machine for not sanitizing properly, replaced a micro pump motor, and increased the sanitizer solution. The facility policy titled Ware Washing stated that proper ware washing is essential to prevent food borne illnesses and that low-temperature dish machines using chlorine sanitizer should be maintained at 50-100 ppm.
Gas Stove Burners Not Lighting Properly
Penalty
Summary
The facility failed to maintain the gas stove in safe operating condition for 1 of 1 stove reviewed for food service. During an observation and interview on 12/8/2025 at 9:36 AM, two of the six gas stove burners, the left front and left back burners, did not light completely when the knob was turned and only half of each burner was lit. The DM stated the stove had been that way for 2 years since she started at the facility and that kitchen staff did not use those two burners. She could not answer what could happen if they did not light properly and said she would let the Administrator know about the stove. During later interviews, the Administrator said the burners had been reported to Maintenance and someone was going to come to the facility that day, and the Maintenance Supervisor said he was not made aware of the problem until 12/9/2025 and that someone was coming that day to look at it. On 12/9/2025, the surveyor requested a policy for the stove, and none was provided by survey exit on 12/10/2025.
Expired insulin left on medication cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of medications on the 300 hall medication cart. During observation of the nurse medication cart, an Insulin Aspart Flex pen was found with no open date and an issue date of 08/08/2025, even though the pharmacy directions indicated it should be discarded 28 days after opening. The cart also contained expired insulin pens that had not been removed from storage. Resident #48 had physician orders for insulin therapy related to type 2 diabetes, including Insulin Aspart Flex pen before meals using a sliding scale and Lantus Solostar 25 units subcutaneously in the morning. The record review identified that the resident was receiving insulin products that were stored on the medication cart, and the expired insulin pen was present in the cart at the time of observation. The DON stated she did not know the cart had expired insulins, discarded the expired insulin, and obtained two new pens for the cart. The facility policy stated injectable medications are to be used according to manufacturer recommendations or pharmacy directions, and that the date opened and triggered expiration date must be recorded on multi-dose vials. The policy also stated that if an opened multi-dose vial does not indicate the date opened, the date opened reverts to the dispensing date, and if the dispensing date cannot be determined, the product should not be used and should be discarded. The Administrator stated the DON was responsible for ensuring medications were labeled and stored as required by regulations, and that expired medications should be removed from medication carts.
Unlabeled Insulin in Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not stored in accordance with accepted professional principles, and one of three medication carts reviewed had insulin that was not labeled with the date it was opened. During observation of the nurse medication cart for the 300 hallway, Lantus Solostar insulin was found with no open date documented on the label or container, although the pharmacy issue date was 11/26/2025 and the pharmacy directions indicated the medication should be discarded 28 days after opening. Record review showed Resident #48 was a male resident admitted with type 2 diabetes. His physician orders included Insulin Aspart Flex Pen for sliding-scale coverage before meals and Lantus Solostar insulin glargine 25 units subcutaneously each morning for type 2 diabetes. The facility policy stated that multi-dose vials and similar injectable medications must have the date opened recorded, and that if an opened multi-dose vial does not indicate the date opened, the dispensing date should be used if known; if not known, the product should not be used. During interview, the DON stated she did not know the medication cart had unlabeled insulins and said she discarded the unlabeled insulin and obtained a new pen for use. She stated that most insulins must be replaced 28 days after opening and that all insulins should have an open date because they are only good for so many days after opening. The Administrator stated the DON was responsible for ensuring medications were labeled and stored as required, and that all insulins and multi-dose vials should be dated when opened and expired medications removed from medication carts.
Expired Food Found in Resident Refrigerator
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident’s food items in a personal refrigerator. During observation, Resident #59’s refrigerator contained a bottle of Miracle Whip that had expired on 9/23/2025, and the expired item remained in the refrigerator during a later observation the next day. Resident #59 was in bed awake at the time of the first observation and stated she had not used the Miracle Whip in a long time and was not aware it was expired. She later said she ate food from her refrigerator and did not know the Miracle Whip was expired. Resident #59’s record showed she was admitted with diagnoses including CHF, COPD, type 2 diabetes, and fusion of spine. Her quarterly MDS indicated moderate impairment in thinking with a BIMS score of 12, partial/moderate assistance with personal hygiene, and that she was always incontinent of urine and bowel. Her care plan identified an ADL self-care performance deficit and risk for not having her needs met in a timely manner, with extensive assistance for toileting. Staff interviews showed the MA said she had recently been told all MAs were responsible for checking personal refrigerators once during the shift, but they were not told to check for expired or old foods. The DON and BOM stated that daily angel rounds included checking refrigerators for cleanliness, temperatures, and expired food items, and the BOM said Resident #59 would not allow staff to clean or check her refrigerator and would tell staff she would do it herself.
Dirty Linen Left on Bathroom Floor
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident. Resident #59 was admitted with diagnoses including congestive heart failure, COPD, type 2 diabetes, and fusion of the spine. Her quarterly MDS indicated moderate impairment in thinking with a BIMS score of 12, partial/moderate assistance with personal hygiene, and that she was always incontinent of urine and bowel. Her care plan identified an ADL self-care performance deficit and extensive assistance for toileting. During observations on 12/8/2025 and 12/9/2025, a dirty towel with a brown substance on it was seen on the floor of Resident #59’s bathroom and remained there across multiple observations. Resident #59 stated she had a small bowel movement that morning and staff had cleaned her up. On 12/9/2025, CNA E observed the dirty towel on the floor, stated nurse aides were responsible for picking up dirty linens and that they should be placed in a plastic bag, and then removed the towel. The DON stated dirty linens should be placed in a barrel in the soiled linen closet and not stored on the floor, and the Administrator stated dirty linens should be placed in the dirty linen barrel in the soiled linen closet.
PASARR Specialized Services Not Submitted or Incorporated Into Care Planning
Penalty
Summary
The facility failed to incorporate PASARR recommendations into resident assessment, care planning, and transition of care for 2 of 9 residents reviewed. For one resident, the record showed an admission with diagnoses including adult failure to thrive, polyneuropathy, cerebral infarction, and GERD, along with a significant change MDS showing no impairment in thinking and a care plan identifying the resident as PASARR positive with ID. A PASARR Comprehensive Service Plan documented an initial meeting and that Specialized OT was a new service, with all services agreed upon at the meeting, but the facility record did not show a NF specialized services form submitted in the SIMPLE portal after that meeting. For the second resident, the record showed diagnoses including end stage renal disease, intellectual disabilities, and Down syndrome, with a quarterly MDS showing severe impairment in thinking and use of a wheelchair. A NFSS therapy signature page was signed by the therapist and administrator, and a PASARR Comprehensive Service Plan documented an annual meeting in which Specialized OT was a new service requested and services were agreed upon. The resident’s PASARR evaluation and Level 1 screening identified ID and DD, and the care plan stated the resident had been deemed PASARR positive and that specialized services determined necessary by the IDT would be initiated and the request submitted within 20 days after the IDT date. During interviews, staff stated that the facility should have entered the meeting information and submitted the NFSS form in SIMPLE after the IDT meeting, and that if services were not provided the residents would not get the therapy they were requesting. The Habilitation Coordinator, DOR, SW, and Administrator each acknowledged gaps in the process, including missed email communication, uncertainty about the submission timeframe, and inability to locate a submitted NFSS form for one resident. The facility policy stated that specialized services were to be submitted within 20 days of the PCSP meeting.
Missed ADL Care and Hygiene Needs
Penalty
Summary
The facility failed to ensure Resident #16, who had dementia, schizophrenia, blindness in the right eye, and hypertension, received needed grooming and oral/personal hygiene. His admission MDS showed severe impairment in thinking with a BIMS score of 3, partial/moderate assistance needed for personal hygiene, and substantial/maximal assistance needed for showering and bathing. His care plan identified an ADL self-care performance deficit and directed staff to provide showers, shave, oral care, hair care, and nail care per schedule and when needed. During observations on 12/8/2025 and 12/9/2025, he was seen in bed with a thick, black substance under his fingernails, and he stated he was not sure when his showers were scheduled and did not remember when his last shower occurred. The facility also failed to ensure Resident #29 had clean clothing. Resident #29 had Alzheimer’s disease, severe cognitive impairment, and an ADL self-care performance deficit on his care plan, which also identified a need to maintain dignity by being clean, dry, odor free, and well-groomed. On 12/8/2025, he was observed in the dining room with his shirt and pants soiled with food, remained in the same soiled clothing at lunch, and was later observed asleep in bed still wearing the same soiled shirt and pants. He was again observed in the dining room for dinner wearing the same soiled clothing. Interviews confirmed the expectations for ADL care and the missed care. A CNA assigned to Resident #29 stated that residents who could not change their own clothes should have their clothes changed when soiled and acknowledged the resident should have been changed before returning to dinner. Another CNA stated nail care should be provided as needed and on shower days, and the DON and Administrator stated residents should not be left in soiled clothes and that nail care and ADL care were the responsibility of nursing staff and nurse aides. Facility policies stated residents would receive essential ADL services to maintain grooming and personal and oral hygiene, and nail care was to provide for personal hygiene needs and prevent infection.
Failure to Secure and Supervise Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one resident. Specifically, staff left medications in a resident's room for the resident to take unsupervised, resulting in the resident dropping one Colace pill and one Amlodipine pill on the floor. The facility's policy required that all medications be stored securely and under the direct observation of the person administering them, or locked in the medication storage area or cart during a medication pass. However, this policy was not followed in this instance. The resident involved was a female with multiple diagnoses, including congestive heart failure, generalized edema, myocardial infarction, chronic obstructive pulmonary disease, constipation, and essential hypertension. She had a BIMS score indicating normal cognition. Her medication regimen included Amlodipine and Colace, which were found on the floor of her previous room. The resident reported that staff did not wait for her to take her medication and that she thought she had dropped some pills, noting that staff were in a hurry and she did not have time to ask what she was taking. Multiple staff interviews confirmed that the pills could have ended up on the floor either by the resident spitting them out when staff were not looking or by staff dropping the pills and not picking them up. Staff acknowledged that medications should not be left on the floor and that there was a risk of another resident finding and taking the medication. The facility's policy and staff statements both indicated that medications should always be kept safe and secured, and that medications should not be left unattended in resident rooms.
Resident Physically Restrained During Incontinence Care
Penalty
Summary
A facility failed to ensure that a resident was free from physical restraint, as required by policy and regulation. During incontinence care, a certified nursing assistant (CNA) physically restrained a male resident with Alzheimer's Disease, ataxia, and severe cognitive impairment by pushing his hands into his chest and holding him down on the bed. The resident, who was dependent on staff for most activities of daily living and was always incontinent, became agitated and combative when awakened for care. Despite the resident's care plan specifying that staff should stop personal care and return later if he became agitated, the CNA continued to attempt care and used physical force to restrain the resident. The incident was witnessed by another CNA, who reported that the resident was startled awake, became combative, and grabbed her hand. The CNA observed her colleague restraining the resident and reported the behavior to the charge nurse. A video recording from the resident's in-room camera confirmed that the CNA held the resident down, and the resident could be heard expressing pain. Interviews with staff and the resident's responsible party corroborated the sequence of events, including the use of force and the resident's distress. The CNA involved was agency staff and had completed required training through the agency but had not previously worked at the facility. The facility's policy prohibits the use of restraints for discipline or convenience and limits their use to situations with a medical symptom warranting restraint. The actions taken by the CNA were not in accordance with the resident's care plan or facility policy, resulting in a deficiency related to the use of physical restraints.
Removal Plan
- CNA A was immediately removed from resident care and suspended then terminated.
- Appropriate notifications to abuse coordinator, RP and providers were made.
- Began ongoing in-service for all staff which covered abuse/neglect and required reporting to the facility abuse coordinator.
- Began ongoing in-service for all staff which covered using no force or minimal force with residents and reporting any pain during personal care to charge nurse. The in-service was provided to all-staff members.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Response to Exit-Seeking Behavior
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple dependencies for activities of daily living was able to exit the facility unsupervised by following visitors out of the building. The resident had diagnoses including unspecified dementia, anxiety disorder, and senile degeneration of the brain, and was assessed as having a BIMS score of 6, indicating severe cognitive impairment. Prior to the incident, the resident had no documented history of wandering or exit-seeking behaviors, and her elopement risk assessments indicated the lowest risk. On the day of the incident, the resident exhibited new exit-seeking behaviors, including attempting to use the phone to go home and asking staff what would happen if she opened the door. These behaviors were documented by an LVN, but no further action was taken to notify other staff or implement interventions. The resident subsequently followed visitors out of the facility, and staff only became aware of her absence when contacted by a neighboring facility where she had gone, believing she was going to work there. The facility's failure to provide adequate supervision and respond to the resident's new exit-seeking behaviors resulted in the resident leaving the premises unsupervised. Although the resident was found unharmed and promptly returned, the lack of immediate intervention and communication among staff contributed to the deficiency. The facility's policies required supervision and individualized care planning for residents at risk of elopement, but these were not effectively implemented in this case.
Failure to Report Fall Incident and Implement Neglect Prevention Policy
Penalty
Summary
The facility failed to implement its written policies and procedures that prohibit and prevent neglect for one resident reviewed for abuse and neglect. Specifically, the facility did not report a fall incident involving a resident to the state agency (HHSC) within 24 hours, as required by its own policy. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, depression, and total dependence on staff for transfers, who was being transferred using a mechanical lift by a nursing assistant (NA) working alone, contrary to the care plan and facility policy requiring two staff for such transfers. During the transfer, the resident began to slide out of the mechanical lift sling, and the NA attempted to prevent a fall by grabbing the resident's shirt and the sling, ultimately lowering the resident to the floor. The resident was assessed by nursing staff and found to have no injuries or pain, and the incident was documented in the medical record. However, the facility did not submit a self-reported incident to the state agency regarding this mechanical lift fall, as required by both facility policy and state regulations for incidents involving potential neglect, regardless of injury. Interviews and record reviews confirmed that the NA was aware of the two-person transfer requirement but proceeded alone due to staffing issues. The facility's abuse prevention policy and reporting guidelines clearly state that all allegations or incidents of neglect must be reported to the state agency within specified timeframes, even if no injury occurs. Despite this, the incident was not reported, and the facility's leadership determined it did not meet the criteria for reporting, citing the absence of injury or harm.
Failure to Timely Report Suspected Neglect During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after forming the suspicion if the events resulted in serious bodily injury, or not later than 24 hours if the events did not result in serious bodily injury. Specifically, the facility did not report to the state agency within 24 hours when a nursing assistant dropped a resident during a mechanical lift transfer. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, depression, and other significant health conditions, who was totally dependent on staff for transfers and required a mechanical lift with two staff members for safe transfer. On the day of the incident, the nursing assistant attempted to transfer the resident alone using a mechanical lift, contrary to the care plan and facility policy requiring two staff members. During the transfer, the resident began sliding out of the sling, and the nursing assistant grabbed the resident's shirt and the sling, lowering the resident to the floor. The resident was assessed by nursing staff and a virtual medical provider, with no injuries or pain reported and neuro checks remaining at baseline. The incident was documented in progress notes, and the nursing assistant provided a written statement confirming the use of the lift without assistance and the improper attachment of sling hooks. Despite the facility's policy requiring immediate reporting of such incidents to the state agency, the event was not reported within the required timeframe. The administrator and regional nurse consultant determined that the incident did not meet the criteria for neglect or reportable events because the resident was not injured. However, the facility's own policy and state regulations require reporting of all alleged violations involving neglect, regardless of injury. The failure to report the incident as required constituted a deficiency in the facility's abuse, neglect, and exploitation reporting procedures.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) transferred a female resident with severe cognitive impairment and total dependence for transfers using a mechanical lift without the required assistance of a second staff member. The resident, who had diagnoses including Alzheimer's disease, dementia, and arthropathy, was care planned for mechanical lift transfers with two staff due to her high risk for falls and inability to communicate effectively. Despite this, the NA attempted the transfer alone, contrary to facility policy and training, and used mismatched sling hooks during the process. During the transfer, the resident began to slide out of the sling. The NA attempted to prevent a fall by grabbing the resident's shirt and the sling, ultimately lowering the resident to the floor between the legs of the lift. The incident was witnessed by other staff who responded to the NA's call for help. Assessment by a licensed vocational nurse (LVN) found no injuries, pain, or change in the resident's baseline condition, and neuro checks remained normal for 72 hours following the event. The NA admitted to transferring the resident alone and acknowledged awareness of the two-person requirement, citing staffing shortages as a reason for acting alone. Facility documentation confirmed that the NA had previously received training on proper mechanical lift use, including the need for two staff and correct sling attachment. The facility's policies and care plans clearly outlined these requirements, but they were not followed during the incident, resulting in an unsafe transfer and a fall to the floor.
Failure in Mechanical Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistance devices during a mechanical lift transfer, resulting in a serious accident involving a resident. The incident occurred when the resident, who was totally dependent on staff for transfers, was being moved using a mechanical lift. During the transfer, one of the straps came off, causing the resident to fall and sustain a subdural hematoma and a left shoulder separation. The resident had a history of severe cognitive impairment and was at risk for falls, which was documented in her care plan. The staff involved in the transfer did not follow proper procedures for using the mechanical lift. Observations revealed that the lift sling was faded and lacked a manufacturer's tag, and the staff did not lock the legs of the lift during the transfer. Interviews with the staff indicated a lack of consistent training and understanding of the mechanical lift's operation. The CNA operating the lift admitted to not applying the brakes during the transfer, which contributed to the resident's fall. The facility did not report the incident to the state agency, as they determined it was an accident. The investigation revealed that the staff were not aware of how the strap came off, and there was no mechanical lift policy in place, only a checklist. The facility's failure to ensure proper training and equipment maintenance led to the resident's injury, highlighting a significant deficiency in the facility's accident prevention measures.
Inaccessible Call Light Strings in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that the emergency call light strings in the bathrooms of three residents were accessible and functional. Observations revealed that the call light strings were either tied in knots or wrapped around grab bars, making them unreachable for the residents if they fell. This deficiency was noted for three residents, each with varying medical conditions, including intellectual disabilities, Down syndrome, end-stage renal disease, type 2 diabetes, fractures, anxiety, and depression disorders. Resident #7, who was at risk for falls due to gait and balance problems, had a call light string in the bathroom that was not long enough to reach the floor. Despite being independent with most activities of daily living, the resident's care plan emphasized the importance of having the call light within reach. Similarly, Resident #65, who was also at risk for falls, had a call light string that was too short, and she was unaware of its inaccessibility. Resident #38, with severe cognitive impairment, had a call light string wrapped around the grab bar, which she did not alter herself. Interviews with staff, including a CNA and the Maintenance Supervisor, revealed a lack of clarity and responsibility regarding the regular checking of call light strings. The Maintenance Supervisor admitted to having a checklist for weekly checks but relied on staff to report issues. The Administrator was unaware of the maintenance checks and acknowledged the need for the call lights to be accessible. The facility's policy required staff to ensure call lights were within reach during each interaction, but this was not consistently practiced.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, specifically affecting the Interim Director of Nursing (DON), the Dietary Manager, and a Certified Nursing Assistant (CNA). The Interim DON, hired on July 30, 2024, did not receive the required training on HIV and restraint reduction until August 14, 2024, and had no training on dementia. The Dietary Manager, originally hired in 2012 and now a contract employee, did not receive annual training on dementia. CNA S, hired on March 15, 2024, did not receive training on HIV and dementia until April 17, 2024, and only received restraint training on August 28, 2024, following a reprimand. Interviews revealed that the Human Resources (HR) personnel responsible for orientation was unaware of the requirement for new hire training to be completed before staff began resident care. The HR personnel typically allowed two weeks for new employees to complete their training. The Administrator confirmed that staff training was conducted via online videos covering various topics, including abuse/neglect and dementia. However, the Administrator acknowledged her responsibility to ensure that staff received the necessary training during orientation and annually, recognizing that failure to do so could negatively impact resident care.
Failure to Complete QAPI Training for Key Staff
Penalty
Summary
The facility failed to ensure that Quality Assurance and Performance Improvement (QAPI) training was completed for three of its employees during their orientation and annual training. Specifically, the Interim Director of Nursing (DON), the Dietary Manager, and a Certified Nursing Assistant (CNA) did not receive the required QAPI training. The Interim DON, hired on a contract basis, did not receive QAPI training upon hire. The Dietary Manager, also a contract employee, did not complete the annual QAPI training. The CNA, hired in March 2024, did not receive QAPI training until a month after starting. Interviews revealed that the Human Resources (HR) personnel responsible for orientation and training was unaware of the requirement for employees to complete mandatory training before starting resident care. The HR representative acknowledged the risk posed by this oversight and committed to implementing a checklist for required trainings. The Administrator confirmed that staff were watching training videos on various topics but admitted responsibility for ensuring that all required trainings were completed during orientation and annually. The facility's policy mandates that training requirements be met before staff independently provide services to residents, highlighting the deficiency in the training process.
Failure to Provide Mandatory Infection Control Training
Penalty
Summary
The facility failed to provide mandatory training on standards, policies, and procedures for an infection prevention and control program to three of its employees: the Interim Director of Nursing (DON), the Dietary Manager, and a Certified Nursing Assistant (CNA). The Interim DON, hired on July 30, 2024, did not receive the required training until August 14, 2024. The Dietary Manager, originally hired in 2012 and now working under contract, did not receive annual training on the infection prevention and control program. The CNA, hired on March 15, 2024, did not receive the necessary training until April 17, 2024. This lack of timely training could potentially place residents at risk of illness due to insufficient staff knowledge. Interviews with the Human Resources (HR) representative and the Administrator revealed gaps in the training process. The HR representative admitted to being unaware of the requirement for training to be completed before employees began resident care, typically allowing two weeks for new hires to complete their training. The Administrator acknowledged responsibility for ensuring staff received required training during orientation and annually, noting that failure to do so could negatively impact resident care. The facility's policy, dated November 29, 2022, mandates that training requirements be met before staff independently provide services to residents, annually, and as necessary based on the facility assessment.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure that three employees, including the Interim Director of Nursing (DON), the Dietary Manager, and a Certified Nursing Assistant (CNA), received the required training on compliance and ethics. The Interim DON, hired on July 30, 2024, did not receive the necessary training upon hire. Similarly, the Dietary Manager, who has been with the facility since June 26, 2012, did not receive annual training on compliance and ethics. Additionally, CNA S, hired on March 15, 2024, also did not receive the required training upon hire. During interviews, the Human Resources (HR) representative acknowledged responsibility for completing orientation and paperwork but was unaware of the requirement for training to be completed before employees began resident care. The HR representative mentioned that new employees were typically given two weeks to complete their training. The facility's Administrator confirmed that staff were watching training videos but emphasized that she was ultimately responsible for ensuring that all required training was completed prior to employment and annually. The facility's policy, dated November 29, 2022, mandates that training requirements be met before staff independently provide services to residents, annually, and as necessary based on the facility assessment.
Failure to Provide Behavioral Health Training
Penalty
Summary
The facility failed to provide mandatory effective behavioral health training for two employees, the Interim Director of Nursing (DON) and a Certified Nursing Assistant (CNA), as required by policy and regulation. The CNA was hired on March 15, 2024, and the Interim DON on July 30, 2024, but neither had completed the necessary behavioral health training upon hire. This lack of training could potentially place residents with behavioral issues at risk of not receiving appropriate care to maintain their highest practicable physical, mental, and psychosocial well-being. Interviews revealed that the Human Resources (HR) personnel responsible for orientation and paperwork was unaware of the requirement for training completion before employees began resident care. The HR representative acknowledged the risk of harm to residents due to staff not receiving necessary training. The facility's administrator confirmed that staff were expected to complete training by watching videos online and acknowledged her responsibility to ensure training was completed prior to employment and annually. The facility policy, dated November 29, 2022, mandates that training requirements be met before staff independently provide services to residents.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to hand hygiene protocols during meal and medication passes. Specifically, CNA F did not wash or sanitize her hands before and after resident contact while distributing meal trays to residents in various rooms. This lapse in hand hygiene was acknowledged by CNA F, who admitted to not sanitizing her hands between resident interactions, despite having received training on proper hand hygiene practices. Medication Aide H was observed using an aerosol disinfectant spray instead of the facility-approved alcohol-based hand sanitizer before administering medications to a resident. She expressed a personal preference for the spray over the alcohol-based sanitizer, despite being aware of the facility's policy. Similarly, Medication Aide M failed to sanitize her hands before and after taking a resident's blood pressure and administering medications. She also noted that the tape on her wrist cuff prevented proper sanitization, potentially contributing to the spread of infections. Additionally, the facility did not ensure that reusable equipment was properly sanitized. An electronic thermometer with sticky tape and debris was found in a medication cart, and the ADON acknowledged that such equipment could not be adequately cleaned, posing a risk of infection transmission. Interviews with the Interim DON and the Administrator confirmed that staff were expected to follow hand hygiene protocols and that the use of broken equipment with tape was against facility policy, as it hindered proper sanitization.
Failure to Report Resident Injury from Mechanical Lift Incident
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident who fell from a mechanical lift, resulting in a right subdural hematoma and a left shoulder joint separation. The incident occurred during a transfer after the resident's shower, when one of the lift straps came off, causing the resident to fall and sustain injuries. Despite the serious bodily injury, the facility did not report the incident to the state agency within the required 2-hour timeframe. The resident involved was admitted to the facility with diagnoses including intellectual disabilities, developmental disabilities, hypertension, and unspecified convulsions. She was totally dependent on staff for transfers and had a care plan that included the use of a Hoyer lift with two CNAs for transfers. On the day of the incident, the resident was being transferred back to her room when the strap malfunction occurred, leading to her fall and subsequent injuries. Interviews with staff involved in the incident revealed that they were unsure how the strap came off and attempted to lower the resident safely, but were unsuccessful. The facility's administrator and regional support team concluded that the incident was an accident and did not meet the guidelines for reporting to the state agency, despite the facility's policy requiring immediate reporting of incidents involving serious bodily injury and neglect.
Failure to Follow Smoking Policy
Penalty
Summary
The facility failed to adhere to its established smoking policy for a resident who was reviewed for smoking. The resident, who had a history of atherosclerotic heart disease, heart failure, type 2 diabetes, and COPD, was found to have smoking materials, including a lighter, in his possession over a period of three days. The resident's care plan indicated that he was a smoker at risk for injury and required staff supervision, with all smoking paraphernalia to be kept at the nurse's station. However, during observations and interviews, it was noted that the resident kept a lighter in his room and on his person, contrary to the facility's policy. The resident admitted to keeping a lighter with him due to past issues with staff not having lighters available during designated smoking times. The facility's administrator confirmed that smoking materials, including lighters, were supposed to be stored at the nurse's station and had previously removed lighters from the resident. The facility's smoking policy, revised in July 2023, mandates that smoking accessories be kept under staff control when not in use. The failure to follow this policy could potentially place residents at risk of injury and create an unsafe smoking environment.
Failure to Provide Required Communication Training to New Staff
Penalty
Summary
The facility failed to ensure that two new employees, the Interim Director of Nursing (DON) and a Certified Nursing Assistant (CNA), received the required training on effective communication during their orientation. The Interim DON was hired on July 30, 2024, and the CNA on March 15, 2024. This oversight was discovered during a review of employee files, which indicated that the necessary training had not been completed. The Human Resources (HR) representative acknowledged the lapse, stating she was unaware that the training needed to be completed before the employees began resident care. She admitted that this could lead to a lack of information for staff and potential harm to residents. During interviews, the HR representative and the Administrator both confirmed the deficiency. The HR representative mentioned that she typically allowed new employees two weeks to complete their training before they started working independently. The Administrator stated that staff were watching training videos on various topics, including abuse/neglect and dementia, but acknowledged her responsibility to ensure all required training was completed during orientation. The facility's policy, dated November 29, 2022, mandates that training requirements be met before staff independently provide services to residents, highlighting the importance of effective communication training for direct care staff.
Deficiency in Staff Training on Resident Rights
Penalty
Summary
The facility failed to ensure that the rights of the residents and the responsibilities of the facility were communicated to two employees, the Interim Director of Nursing (DON) and a Certified Nursing Assistant (CNA), during their orientation. This deficiency was identified through interviews and a review of employee records, which revealed that these staff members had not completed the required training on resident rights and facility responsibilities. The Interim DON was hired on July 30, 2024, and the CNA on March 15, 2024, yet neither had completed the necessary training at the time of the survey. During interviews, the Human Resources (HR) representative acknowledged her responsibility for completing orientation and other paperwork but admitted she was unaware of the requirement for training to be completed before staff began resident care. The HR representative stated that she typically allowed new employees two weeks to complete their training. The facility's Administrator confirmed that staff were expected to complete training on various topics, including resident rights, before starting employment. The facility's policy, dated November 29, 2022, mandates that training requirements be met before staff independently provide services to residents.
Failure to Complete Mandatory Training for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA S, completed mandatory training in Abuse, Neglect, and Exploitation (ANE) and dementia management during their orientation. This deficiency was identified through interviews and a review of employee records, which revealed that CNA S, who was hired on March 15, 2024, had not completed the required trainings. The Interim Director of Nursing (DON) acknowledged that all nursing staff were expected to complete these trainings during orientation and annually, and that failure to do so could result in residents not receiving the necessary care. Interviews with the Human Resources (HR) representative and the Administrator further highlighted the oversight. The HR representative admitted to being unaware of the requirement for these trainings to be completed before staff began resident care, and stated that a checklist would be implemented to ensure compliance in the future. The Administrator confirmed that staff were expected to complete training videos on various topics, including abuse/neglect and dementia, and acknowledged her responsibility for ensuring these trainings were completed. The facility's policy, dated November 29, 2022, mandates that training requirements be met prior to staff independently providing services to residents.
Failure to Provide Required Training for Staff
Penalty
Summary
The facility failed to ensure that two staff members, the Interim Director of Nursing (DON) and a Certified Nursing Assistant (CNA), received the required training on Abuse, Neglect, and Exploitation, as well as dementia management during their orientation. This deficiency was identified through interviews and record reviews, which revealed that these staff members had not completed the necessary training before beginning resident care. The Interim DON was hired on July 30, 2024, and the CNA on March 15, 2024, yet neither had completed the mandatory training as per the facility's policy. During interviews, the Human Resources (HR) representative admitted to being unaware of the requirement for these trainings to be completed before staff began resident care. The HR representative typically allowed new employees two weeks to complete their training, which was not in compliance with the facility's policy. The Administrator confirmed that staff were expected to complete training via online videos, covering topics such as abuse/neglect, dementia, and resident rights, but acknowledged the responsibility to ensure these trainings were completed prior to employment and annually. The facility's policy, dated November 29, 2022, mandates that training requirements be met before staff independently provide services to residents.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse and neglect, as evidenced by several incidents involving both staff and resident-to-resident altercations. One incident involved a housekeeper verbally abusing a resident by using profane language during a confrontation. Despite the altercation, the housekeeper was allowed to return to work shortly after the incident. Additionally, there was a lack of documentation regarding the incident in the resident's progress notes. Another significant issue was the failure to prevent resident-to-resident physical altercations. Several residents with cognitive impairments were involved in physical conflicts, such as hitting and slapping each other. These incidents were not consistently documented in the residents' progress notes, and there was insufficient evidence of effective interventions or monitoring to prevent further occurrences. The facility's incident reports and investigation documents highlighted these altercations, but there was a lack of follow-up in terms of behavioral health assessments and interventions. The facility also failed to provide adequate supervision and monitoring for residents with known behavioral issues. For instance, residents with severe cognitive impairments and a history of behavioral disturbances were not consistently monitored, as evidenced by gaps in staffing schedules for one-on-one supervision. This lack of supervision contributed to the occurrence of altercations and the facility's inability to protect residents from harm. The surveyor's request for behavior monitoring and intervention reports was not fulfilled, indicating a lack of comprehensive documentation and oversight.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 11 of 18 residents reviewed for abuse policies. This deficiency was highlighted by multiple incidents of abuse involving both staff and residents. For instance, a housekeeper verbally abused a resident by calling her a derogatory name, and there were several instances of resident-to-resident physical altercations. These incidents were not adequately documented or addressed in the residents' care plans or progress notes, indicating a lack of effective monitoring and intervention strategies. Resident #1, who had a BIMS score indicating no cognitive impairment, was involved in multiple altercations, including being verbally abused by a housekeeper and physically assaulted by other residents. Despite these incidents, there was insufficient documentation in her progress notes, and the facility failed to provide requested behavior monitoring and interventions reports. Similarly, Resident #2, who was cognitively intact, was hit by another resident, yet the psychological services progress note did not address the altercation. The facility also failed to protect residents from abuse by other residents, as seen in the case of Resident #4, who slapped another resident after being inappropriately touched. The facility's incident reports and staffing schedules did not consistently reflect 1:1 monitoring or interventions for residents involved in altercations. Additionally, the facility did not provide behavior monitoring and interventions reports for several residents by the time of the surveyor's exit, further demonstrating a lack of comprehensive and effective abuse prevention measures.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for three residents. For Resident #13, the facility did not implement interventions to prevent pressure ulcers, failed to conduct ongoing skin assessments, and did not follow the wound care physician's recommendations. This resident had multiple pressure wounds, including a stage 4 pressure ulcer, and an undocumented wound on the right posterior ankle that went untreated. The facility also did not ensure the use of pressure off-loading boots or a low air loss mattress for this resident. Resident #14 also experienced a lack of proper care, as the facility did not implement interventions to prevent pressure ulcers and failed to conduct weekly skin assessments or document wound measurements. This resident had a stage 4 pressure ulcer on the sacrum and a skin tear on the left ischium. Additionally, an arterial wound on the left heel was not identified or treated by the facility staff, and the resident had to use a makeshift padding to prevent further injury from the wheelchair footrest. For Resident #15, the facility did not ensure that preventative equipment was in working order, as the resident was found lying on a deflated low air loss mattress. This resident had a stage 4 pressure wound on the left heel, and the deflated mattress failed to provide necessary pressure relief, potentially worsening the resident's condition. The facility also did not conduct weekly skin assessments or document wound measurements for this resident.
Inadequate Supervision and Safety Measures During Resident Transport
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistance devices to prevent accidents for a resident during transport in the facility van. On two separate occasions, the resident fell out of his wheelchair while being transported. The first incident occurred when the resident slid out of his wheelchair, resulting in a dressing change due to fluid saturation, although no injuries were observed. The second incident involved the resident's wheelchair lifting off the floor due to defective floor straps, but again, no injuries were reported. Interviews with staff revealed that the transport driver did not use safety harnesses during the transport, as the resident refused to wear them. The driver was trained on using the safety harness-lap belt but chose to drive slowly instead to prevent falls. Additionally, the facility's maintenance supervisor, who was responsible for training new drivers, had not been trained on van safety and was unsure of who would conduct such training. The facility's van was found to have worn straps that could release if pulled hard enough, and there was no evidence of regular maintenance checks being conducted. The facility's transportation policy required drivers to ensure residents were secured with seat belts, and if a resident refused, they should not be transported. However, this policy was not followed, leading to the incidents. The facility's failure to provide adequate training and maintenance checks contributed to the deficiency, placing residents at risk for serious injury and accidents.
Unsanitary Conditions in Resident Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in four resident shower rooms, as observed and reported by staff. The shower rooms on halls 100, 200, 300, and 400 were found to have a black substance, identified as mold, on the tiles, baseboards, and where the floor and wall met. The 400-hall shower room was out of order and cluttered with stored items, including a mechanical lift and wheelchair. The 100-hall shower room had a strong vinegar smell due to a maintenance attempt to address a gnat issue. The 200-hall shower room was used for storage of personal items and staff belongings, including a cell phone being charged. Staff interviews confirmed the presence of mold and the need for deep cleaning, with some staff expressing discomfort at the thought of using the facilities in their current state. The Housekeeping Supervisor acknowledged the presence of black mold and the need for recaulking and scrubbing of the floors, noting that the condition had persisted for about two weeks. The Administrator admitted awareness of the mold issue and the expectation for daily cleaning, although she was unsure of the cleaning methods used. Despite the expectation for cleanliness, there was no facility policy provided for cleaning procedures. The lack of regular inspections by the Administrator and the absence of a cleaning policy contributed to the ongoing unsanitary conditions in the shower rooms.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that six nurse aides, who had been employed for more than four months, completed a nurse aide competency evaluation program. These aides, identified as NA H, NA K, NA L, NA M, NA O, and NA P, were working without the necessary certification, which placed residents at risk of receiving care from individuals whose skill levels were not verified. The facility's staff roster and personnel files confirmed that these aides had not completed the required training and competency evaluation program approved by the state. Observations and interviews revealed that NA L, who had been employed for over a year and working as an aide for nine months, was not certified. Despite this, she was assigned to provide all activities of daily living (ADL) care to residents on her hall. NA L admitted to not having completed the skills or written tests required for certification and was unaware of any scheduled test dates. The Assistant Director of Nursing (ADON) Q acknowledged the oversight in ensuring that non-certified aides received the necessary training and certification within the four-month timeframe. Further interviews with facility staff, including the Regional Nurse Consultant and the Administrator, highlighted a lack of awareness and oversight regarding the certification status of non-certified aides. The Regional Nurse Consultant confirmed that the facility was not part of the NATCEP program and that the waiver allowing non-certified aides to work had ended. The Administrator admitted to being unaware that non-certified aides were providing care independently, which contradicted the facility's policy that required aides to work alongside certified nurse aides. The facility's policy emphasized the need for sufficient staff with appropriate competencies to ensure resident safety and well-being.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving two residents within the required timeframe. On December 30, 2023, a staff member observed Resident #8 in the room of Resident #9 with his hands under the covers, feeling Resident #9's breasts. Despite being notified of the incident, the Administrator did not report it to the state agency within the mandated two-hour window. The facility's policy requires immediate reporting of such allegations, but this protocol was not followed. Resident #9, who has severe cognitive impairment due to Alzheimer's Disease, was admitted to the facility with a BIMS score indicating severe impairment in thinking. She requires assistance with personal hygiene and decision-making. Resident #8, diagnosed with intellectual disabilities and major depressive disorder, also has severe cognitive impairment and a history of inappropriate sexual behaviors. Despite these known issues, the incident was not reported as required, and the Administrator did not perceive it as abuse, citing the lack of emotional distress in Resident #9. Interviews with staff, including the LVN and DON, revealed that the incident was documented, and the Administrator was informed. However, the Administrator did not take the necessary steps to report the incident to the state agency, as required by the facility's policy. The Regional Director of Operations confirmed that the incident should have been reported, highlighting a failure in the facility's abuse reporting procedures.
Failure to Notify Physician of Resident's Condition
Penalty
Summary
The facility failed to notify and consult with the resident's physician when there was a need to alter treatment for a resident who had not had a bowel movement for 14 days. This resident, who had a history of hemiplegia, hemiparesis, and other medical conditions, was admitted to the hospital with severe health issues, including respiratory failure, sepsis, and stercoral colitis, and subsequently expired. The facility's failure to monitor and report the resident's bowel movements led to a lack of timely medical intervention. Interviews with facility staff revealed that CNAs were responsible for monitoring and documenting bowel movements, but there was a breakdown in communication and documentation. Several CNAs and nurses reported not being aware of the resident's prolonged lack of bowel movements, and the physician was not informed of any concerns regarding constipation or fecal impaction. The facility's electronic health record system, which should have alerted staff to the issue, was reportedly affected by internet outages, further complicating the situation. The facility's policy on bowel monitoring was not effectively implemented, as staff failed to follow the guideline of notifying the physician if a resident had not had a bowel movement for three days. The lack of communication and adherence to protocols resulted in the resident's condition deteriorating without appropriate medical intervention, ultimately leading to her hospitalization and death.
Removal Plan
- Completion of Investigation Synopsis Timeline of Events
- Like Resident: bowel assessment validation completed on all facility residents; no residents identified with no bowel movements over 3 days
- Inservice completed on clinical practice guidelines: bowel movement monitoring and reporting no bowel movement for 3 days with post-test
- Inservice completed on notification of changes with post-test
Failure to Monitor Bowel Movements Leads to Resident's Decline
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident who experienced a significant change in condition. The resident, who had a history of hemiplegia, hemiparesis, and other medical conditions, did not have a bowel movement for 14 days. Despite having interventions in place for monitoring bowel movements and notifying the physician as needed for constipation, these measures were not effectively implemented. The resident was eventually sent to the emergency room with labored breathing and a change in mental status, where it was discovered that she had a contained fecal perforation in her rectum. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's bowel movements. Several CNAs and nurses reported that they were either unaware of the resident's prolonged period without a bowel movement or did not report it due to a lack of communication during shift changes. The facility's policy required monitoring and reporting of residents who had not had a bowel movement for three days, but this was not adhered to in the case of the resident. The resident's condition deteriorated, leading to hospitalization and eventual death due to severe sepsis and complications from fecal impaction. The facility's failure to monitor and document the resident's bowel movements as per the care plan and policy resulted in a critical oversight. The lack of timely intervention and communication among staff members contributed to the resident's decline in health. Interviews with the medical director and other staff indicated that the issue was considered an isolated incident, but it highlighted significant gaps in the facility's monitoring and reporting processes.
Removal Plan
- An in-service was conducted with facility staff on bowel monitoring clinical practice guidelines.
- Facility staff completed bowel assessment on all residents identified with no bowel movements; residents identified as no bowel movement were placed in monitoring for signs/symptoms of constipation and MD notified of any abnormal symptoms.
- Education was provided to nursing staff on bowel movement monitoring and to report when a resident has no bowel movement.
- Education was provided to nursing staff on notification of changes and how to report a resident that had a change in condition.
- Education was provided to supervisory staff on obtaining bowel monitoring reports.
- Interventions were put in place to ensure it does not happen again to include pulling a full bowel movement report and completing in-services with nursing staff to pull bowel movement report every shift.
- The charge nurses are pulling the bowel movement report and aides would be responsible for monitoring bowel movements.
- A Performance Improvement Project Report titled Bowel Movement Monitoring was started with a goal to establish a procedure to avoid constipation or fecal impaction.
- DON/Designee to pull no BM report; resident is to be monitored for signs/symptoms of constipation and notify MD of any abnormal symptoms.
- Results of no BM report will be discussed with admin/DON during morning clinical start up meeting.
- Review findings at QAPI meeting to ensure compliance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crockett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitehall Rehab & Nursing | 0 mi | ★★★★★ | 11 | 0 |
| Houston County Nursing Home | 10.7 mi | ★★★★★ | 0 | 0 |
| Avir At Elkhart | 22.2 mi | ★★★★★ | 1 | 0 |
| Groveton Nursing Home | 25.2 mi | ★★★★★ | 4 | 0 |
| Trinity Rehabilitation & Healthcare Center | 26.2 mi | ★★★★★ | 37 | 3 |
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