Woodland Springs Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 1010 Dallas St, Waco, Texas 76704
- CMS Provider Number
- 675360
- Inspections on file
- 32
- Latest survey
- March 2, 2026
- Citations (last 12 mo.)
- 7 (1 serious)
Citation history
Health deficiencies cited at Woodland Springs Nursing Center during CMS and state inspections, most recent first.
A resident with severe dementia and a history of exit-seeking, housed on a secured unit, became agitated, insisted on leaving to get a beer, and was unable to be calmed by staff or his POA over the phone. After returning to his room, he used a butter knife to remove bolts from his window, pushed out the screen, climbed out, and then exited the grounds through a secured gate whose latch mechanism had not fully engaged after earlier use. The gate was later found ajar. The resident walked a few blocks to a corner store in a high-crime area at a busy intersection, purchased a beer, and returned independently about 20 minutes later. The incident occurred despite existing care plans and policies for safety, supervision, and wandering/elopement, and it was determined that the combination of the unsecured gate and the resident’s ability to manipulate the window hardware led directly to the elopement.
A resident with complex medical needs was not given prescribed antibiotics after hospital discharge due to failures in entering and following medication orders. Staff interviews revealed confusion over responsibilities for order entry and medication administration, resulting in missed doses and a delay in treatment, contrary to facility policy on resident rights and dignity.
A resident with complex medical needs did not receive prescribed antibiotics after returning from a hospital stay due to failures in medication reconciliation and order entry. Staff interviews revealed that discharge medication orders were not promptly entered into the electronic system, and confusion existed regarding medication availability and pharmacy procedures. The resident's antibiotics were missed until the issue was raised by the resident and investigated by staff.
The facility did not ensure its activities program was led by a qualified professional, as the current Activity Director lacked the required certification and could not provide evidence of enrollment in the necessary training. The Administrator was unaware of the AD's certification status, and the facility lacked a policy regarding activities or the qualifications for the director role.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A resident with documented diagnoses of schizoaffective disorder, bipolar type, and borderline intellectual functioning was not properly identified for a Level II PASRR evaluation, despite multiple records indicating active mental illness and use of antipsychotic medication. Facility staff acknowledged that the required PASRR process was not completed, and the resident did not receive PASRR services as mandated by facility policy.
A resident with significant mobility and cognitive impairments, who was on anticoagulant therapy, was not provided adequate supervision or proper assistance during a transfer, resulting in a head injury after striking a cabinet. Despite care plan requirements for two-person mechanical lift transfers, only one CNA was observed entering the room with the lift, and staff accounts of the incident were inconsistent. The resident developed symptoms of head trauma and was not promptly transferred to the hospital, ultimately passing away from a subdural hematoma confirmed by autopsy.
A resident with severe vision impairment did not receive proper coordination for eye care appointments and procedures, including missed or delayed appointments, failure to maintain NPO status before surgery, and lack of timely medical clearance. Facility staff did not consistently communicate or designate responsibility for managing the resident’s care, resulting in deficiencies in treatment and adherence to professional standards.
A resident with mental illness reported being assaulted by another resident, resulting in a head injury. The allegation was documented during a PASRR meeting, but staff did not immediately report the incident to the State Survey Agency as required. Staff interviews revealed a lack of awareness of the allegation, and records showed no timely self-report was made, despite facility policy and training on abuse, neglect, and exploitation (ANE) reporting.
A resident with severe cognitive impairment eloped from a facility through an unalarmed window, remaining missing for three hours in freezing temperatures. The absence was discovered when the resident was not in their usual breakfast seat, prompting a search that revealed an open window. The resident was found by police, highlighting a lapse in supervision and security measures.
A facility failed to protect residents from an aggressive resident who verbally harassed and injured others. Despite a history of aggressive behavior, the facility did not implement effective interventions or report incidents to the state. This resulted in an Immediate Jeopardy situation, with residents expressing fear and staff acknowledging the lack of a behavior modification plan for the aggressive resident.
A facility failed to implement and follow its policies to prevent abuse and neglect, particularly concerning a resident with a history of aggressive behavior. This resident, diagnosed with multiple disorders, repeatedly exhibited verbal aggression towards staff and other residents, culminating in a physical altercation. Despite being aware of the behavior, the facility's staff did not report the incidents as required, and the facility's policy for managing aggressive residents was not effectively implemented, putting all residents at risk.
A facility failed to implement a comprehensive care plan for a resident with aggressive behaviors, leading to repeated verbal aggression and a physical altercation with another resident. Despite the resident's history of hemiplegia, mood disorder, and intermittent explosive disorder, no behavior modification plan was in place. The facility's inaction put other residents at risk, with some expressing fear of the aggressive resident.
A facility failed to administer prescribed medications to three residents, leading to multiple omissions without documented reasons. Despite other medications being given, residents with conditions like hypertension, schizophrenia, and glaucoma did not receive essential medications. The MD and DON expressed concerns about the impact of these omissions on therapeutic levels.
A facility failed to report a resident-to-resident altercation involving a resident with a history of explosive disorder and another with Alzheimer's disease. The incident, which involved verbal harassment and an attempted physical attack, was not reported to the state agency within the required 2-hour period. The administrator did not report the incident, believing there was no intent to harm, and the DON was unsure if it was reportable. This failure to adhere to the facility's policy on immediate reporting of abuse incidents could place residents at risk.
A resident with multiple health conditions was at risk of infection due to a medical assistant's failure to sanitize a wrist blood pressure monitor before use. Despite being aware of the importance of sanitizing equipment, the MA neglected this step while focusing on medication administration. The facility's policy required such sanitization, but no recent training on disinfection was conducted.
Elopement of Cognitively Impaired Resident Through Window and Unlatched Secured Gate
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision to prevent an elopement by a cognitively impaired resident. The resident was an adult male with diagnoses including unspecified dementia, unspecified mood disorder, and primary hypertension. His most recent Quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment. He was care planned for impaired cognitive function due to dementia and identified as an elopement risk, with interventions that included redirection and education on the protocol and hazards of leaving the facility. Despite this, he was placed on a secured unit for exit-seeking behaviors and remained at risk for unsafe wandering and elopement. On the evening of the incident, the resident was at the nurse’s station yelling that he was an adult, could leave if he wanted, and requesting a beer. Staff attempted verbal redirection without success and contacted his POA by phone to help calm him. During the phone conversation, the resident became increasingly agitated, yelled at the POA, and then returned to his room while continuing to argue. Shortly thereafter, when the LVN went to reassess him, the resident was not in his room, bathroom, or closet. The window appeared closed, but the bottom of the screen had been pushed back, which the LVN did not initially recognize. The resident later reported that he had used a butter knife from lunch to remove bolts from his room window, climbed out, closed the window behind him, and then slid under the privacy fence to leave the premises. The resident exited the secured unit through a back gate that was found ajar. Interviews with the DON, ADM, Maintenance Supervisor, and Maintenance Worker established that the secured gate’s latch mechanism did not lock properly and that the gate had last been used earlier in the day when a funeral home picked up a body. The Maintenance Worker stated he was expected to ensure the gate was latched properly and had visually checked it, but it was later determined that the latch did not fully engage. This malfunction allowed the resident, who had severe dementia and was on a secured unit for exit-seeking, to leave the facility grounds, walk to a nearby corner store in a high-crime area at a busy intersection, purchase a beer, and return independently approximately 20 minutes later. The facility’s policies on safety, supervision, wandering, and elopement existed, but the combination of the unsecured gate, the resident’s ability to manipulate the window hardware, and the failure to detect his departure in real time led directly to the elopement event. Additional interviews further described the resident’s condition and behavior at the time of the incident. The resident stated he felt bored, felt like he was in prison, and believed he was in his hometown, where he was familiar with going to a local store for beer and tacos. He reported that he was not afraid of the neighborhood and did not realize he was not in his hometown. The Nurse Practitioner and Medical Doctor both confirmed that the resident had a BIMS score of 3, was on the secured unit for exit-seeking, and was not able to fully understand the consequences of leaving the facility unattended due to his dementia and inability to perform instrumental activities of daily living. The POA corroborated that the resident had dementia, often needed to be spoken to like a toddler, had difficulty remembering family members but could recall past activities, and believed he was in his hometown when he left through the side gate to go to the store. These factors, combined with the malfunctioning gate latch and the resident’s ability to defeat the window screen, resulted in the elopement and constituted the cited deficiency in accident prevention and supervision.
Failure to Provide Prescribed Antibiotics Upon Readmission
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including paraplegia, a stage four pressure ulcer, acute osteomyelitis, and scoliosis, was not provided with prescribed antibiotic medications following discharge from the hospital. The resident was discharged with orders for two antibiotics, Linezolid and Cipro, to be administered for several days. Upon readmission to the facility, the antibiotics were not provided as ordered, and the resident reported not receiving the medications when asked. Interviews and record reviews revealed that the process for entering hospital discharge orders into the facility's electronic system was not consistently followed. The charge nurse on duty did not input the orders, and there was confusion among staff regarding the responsibility for ensuring the medications were available and administered. The resident had to inquire about his antibiotics, prompting staff to investigate and eventually identify the missing orders. It was noted that one of the antibiotics was available in the facility's emergency kit, but the other was not, and there were delays in obtaining it from the pharmacy. Staff interviews indicated that the breakdown in communication and order entry led to the resident missing doses of his prescribed antibiotics. The facility's policy emphasized the importance of treating residents with respect and dignity, including the right to receive medications as ordered. The failure to provide the antibiotics as prescribed constituted a violation of these rights and the facility's own policies.
Failure to Administer Prescribed Antibiotics After Hospital Discharge
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including paraplegia, a stage four pressure ulcer, acute osteomyelitis, and scoliosis, did not receive prescribed antibiotics following discharge from the hospital. The resident was discharged from the hospital with orders for two antibiotics, Linezolid and Cipro, to be administered twice daily for several days. Upon readmission to the facility, the antibiotics were not promptly administered as prescribed. Interviews and record reviews revealed that the process for entering hospital discharge medication orders into the facility's electronic system was not consistently followed. The charge nurse on duty did not input the orders, and there was confusion among staff regarding the presence of the antibiotics in the facility's emergency kit and the process for obtaining medications from the pharmacy. The resident himself brought the missing antibiotics to the attention of the staff, prompting further investigation and eventual notification of the nurse practitioner. Facility staff, including the LVN, charge nurse, and DON, acknowledged that the resident did not receive the antibiotics as ordered and described the process failures that led to the omission. The facility's medication reconciliation policy required verification and timely ordering of medications upon admission, but these steps were not completed, resulting in the resident missing doses of critical antibiotics.
Unqualified Activity Director Leading Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required. The individual serving as the Activity Director (AD) had been in the role since March 2025, following the termination of the previous AD in February 2025. The current AD reported that she had previously worked as an assistant AD and CNA, and had not yet started her certification process for the AD position. Although she stated she was enrolled in the appropriate class, she was unable to provide any evidence of enrollment during the survey. The Administrator (ADM) confirmed that the current AD was promoted from the assistant position and believed she was in the process of obtaining the necessary certification, with plans for reimbursement upon completion. However, the ADM did not have any documentation to verify the AD's enrollment in the required classes. Additionally, the facility did not have a policy regarding the activities program or the qualifications for the activities director. Review of the job description indicated that the AD should be a qualified therapeutic recreation specialist, licensed or registered as applicable by the state, which was not met in this case.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Complete PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to identify and act upon a diagnosis of mental illness for a resident during the preadmission screening and resident review (PASRR) process. Despite the resident having documented diagnoses of schizoaffective disorder, bipolar type, and borderline intellectual functioning, the Level I PASRR screening incorrectly indicated that the resident did not have a primary diagnosis of mental illness, intellectual disability, or developmental disability. The resident's medical records, including the face sheet, MDS assessment, care plan, and physician orders, all reflected active mental health diagnoses and the use of antipsychotic medication for schizoaffective disorder, bipolar type. Interviews with facility staff revealed that a Level II PASRR evaluation was not completed for the resident, even though the Level I screening should have triggered further assessment due to the mental illness diagnoses. The DON and ADON/MDS coordinator acknowledged the oversight, noting that PASRR services were not provided and that therapy services received by the resident were not through PASRR. Facility policy requires all new admissions and readmissions to be screened for mental disorders, intellectual disabilities, or related disorders, and mandates referral for Level II evaluation when indicated, but this process was not followed in this case.
Failure to Provide Adequate Supervision and Safe Transfer Leading to Resident Injury and Death
Penalty
Summary
A deficiency occurred when the facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for a resident who was on anticoagulant therapy. The resident, who had a history of hemiplegia, morbid obesity, and moderate cognitive impairment, required extensive to total assistance for transfers, with care plan interventions specifying the use of a mechanical lift and two staff for transfers. Despite these requirements, video footage showed a CNA entering the resident's room alone with a mechanical lift, and there was conflicting staff testimony regarding the transfer process. The resident experienced a transfer incident where she slid to the floor, and it was reported that she may have struck her head on a cabinet during repositioning. Following the incident, the resident developed symptoms including nausea, vomiting, headache, and increased weakness. Nursing notes indicated that neurological checks were performed, but there was no immediate escalation or transfer to the hospital until several hours later, despite the resident's ongoing symptoms and her report of head trauma. The resident was eventually transferred to the hospital, where she was found to have an acute on chronic subdural hematoma and subsequently passed away. The autopsy confirmed blunt force trauma to the head as the cause of death, with findings consistent with a fall and significant contusions. Interviews with staff revealed inconsistencies in the accounts of the transfer and the events leading up to the resident's injury. The facility's policies required two-person assistance for mechanical lift transfers and immediate reporting and escalation of suspected head injuries, but these protocols were not followed. The failure to adhere to established safety procedures and to provide adequate supervision and timely medical intervention contributed to the resident's injury and subsequent death.
Failure to Coordinate and Prepare Resident for Eye Care Appointments and Procedures
Penalty
Summary
The facility failed to ensure that a resident with severe vision impairment and a diagnosis of glaucoma received treatment and care in accordance with professional standards, the comprehensive care plan, and the resident’s preferences. Specifically, the facility did not adequately prepare the resident for scheduled eye doctor appointments, resulting in missed or delayed care. The resident was not informed of appointment times and relied on the facility to manage his schedule, but there were instances where he was not checked out after appointments, leading to missed follow-ups. The facility also failed to communicate effectively with the eye doctor’s office, as evidenced by multiple unreturned calls and voicemails regarding appointment scheduling. On one occasion, the resident was not kept NPO (nothing by mouth) prior to a scheduled eye surgery, despite clear instructions provided to the facility. The resident was taken to the dining room for breakfast and lunch on the day of the procedure, which led to the surgery being canceled and rescheduled. The eye doctor’s office was not notified by the facility or the resident about the NPO violation; instead, the surgery center informed them after the fact. Additionally, the facility did not ensure that the required medical clearance was obtained prior to another scheduled eye procedure. The eye doctor’s office had to complete the clearance at the last minute to avoid further delay in the resident’s care. Interviews with facility staff revealed a lack of clear responsibility and coordination for managing appointments and pre-operative requirements. The DON, ADM, and activities staff described a collaborative approach but did not designate a specific individual to oversee appointment logistics. There was also a lack of awareness among staff regarding missed appointments, NPO status, and the need for medical clearance, which contributed to the deficiencies in care. Facility policy required advance planning and communication for transportation and appointments, but these procedures were not consistently followed for this resident.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency. Specifically, an incident was identified in which a resident with a history of paranoid schizophrenia and schizoaffective disorder reported during a PASRR LA Update meeting that he had been assaulted by another resident in the secured unit, resulting in a bump on his head. The date of the alleged occurrence was unknown, and the resident stated that the facility would not call 911 or allow him to call 911. The allegation was documented in the PASRR Comprehensive Service Plan (PCSP) Form, but there was no evidence that the incident was reported to the State Survey Agency as required. Record review showed that a fax was sent to Health and Human Services with a brief narrative of the allegation, but there was no fax confirmation included, and the Texas Unified Licensure Information Portal did not reflect an initial self-report by the facility for the incident. Interviews with staff, including the ADON, CNA, RN, social worker, and psychiatric NP, revealed that none of them were aware of the allegation until it was brought to their attention by surveyors. The administrator confirmed he was not aware of the incident until shown the documentation and stated that the PASRR person should have reported it to him. Facility policy and staff interviews confirmed that all allegations of abuse, neglect, or exploitation should be reported immediately, regardless of the resident's history of making false allegations. Both residents involved had significant cognitive or psychiatric impairments, with one resident having moderate cognitive impairment and a history of mental illness, and the other having severe cognitive impairment due to dementia. Staff interviews indicated that they were trained in abuse, neglect, and exploitation (ANE) reporting and that regular in-services were conducted. However, the failure to report the allegation as required by policy and regulation constituted a deficiency, as it could place residents at risk of abuse, neglect, pain, and diminished quality of life.
Resident Elopement Due to Inadequate Supervision and Window Security
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with severe cognitive impairment and multiple other conditions, including dementia and psychosis. The resident, who was at risk for elopement, was missing from the facility for approximately three hours during early morning hours when temperatures were between 28 to 30 degrees Fahrenheit. The resident was last seen around 5:00 am near the day room and was later found by local police at 8:00 am. The resident's elopement was discovered when a CNA noticed the resident was not in his usual seat for breakfast. A search of the facility and surrounding areas was initiated, and it was found that the resident's window was ajar, indicating the point of exit. The facility's doors were alarmed, but the windows were not, which allowed the resident to leave unnoticed. The resident was eventually located by the police, who had been notified of the missing resident. Interviews with the facility's staff, including the DON and CNA, revealed that the resident's absence was not immediately noticed due to a lack of initial headcount and supervision. The resident's elopement posed significant risks, including potential harm from hypothermia, as noted by the MD. The facility's policy on safety and supervision was not effectively implemented, leading to this incident.
Failure to Protect Residents from Aggressive Behavior
Penalty
Summary
The facility failed to protect residents from an aggressive resident, identified as Resident #52, who exhibited behaviors that posed a risk to other residents. Resident #52 had a history of using profanity and being verbally aggressive towards staff and other residents, as documented in his care plan. Despite these documented behaviors, the facility did not implement effective interventions to manage his aggression, leading to an incident where Resident #52 verbally harassed Resident #42 and threw an object that injured Resident #62, requiring her to be taken to the hospital for evaluation. Interviews with residents and staff revealed that Resident #52's aggressive behavior was a known issue within the facility, with several residents expressing fear of him. The Director of Nursing (DON) and the Administrator were aware of the incidents but did not take adequate steps to report or address the aggressive behavior. The Administrator admitted to not reporting the incident to the state, as he believed the injury to Resident #62 was unintentional. The facility's policy on abuse prevention and resident-to-resident altercations was not effectively implemented, as evidenced by the lack of special interventions for Resident #52's behavior. The facility's failure to manage Resident #52's behavior and protect other residents from harm resulted in an Immediate Jeopardy (IJ) situation. The facility did not have a behavior modification plan in place for Resident #52, and staff interventions were largely unsuccessful. The Administrator and staff were aware of the requirement to report abuse within 24 hours but failed to do so, further exacerbating the situation. The lack of effective interventions and reporting placed residents at risk for abuse and harm.
Removal Plan
- The Medical director was notified of the current IJ at the facility.
- Resident # 52 was admitted to hospital.
- Resident # 52 admitted via emergency detention order.
- Abuse policies were reviewed/updated.
- The Administrator/designee re-educated all staff on facility abuse policies.
- The administrator/DON were provided re-education from the corporate nurse and COO.
- All residents were reviewed by the SW and marketing director with no aggressive behaviors found.
- The administrator/designee provided re-education to all staff on abuse prevention and reporting.
- The DON and designee educated Nurse Aides and Licensed Nurses on documenting behaviors. Behavior documentation will be monitored by the Social Services Director or designee and care plans will be updated as indicated. Staff will be educated on new interventions either verbally or in written form by the Care Plan Coordinator or designee.
- In the event of any future resident to resident abuse, the perpetrating resident will immediately be placed on 1:1 supervision until primary care, nursing, and psychiatric evaluations can be complete. Outcomes of these evaluations will result in continued 1:1 supervision or the initiation of discharge planning to a facility with a focus on behavior management.
- New staff will be educated and trained on facility abuse policies upon hire during general orientation.
- Agency staff will be educated and trained on facility abuse policies prior to starting shift.
- Abuse Prevention and Response policies made available for review at all times.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement and follow its policies and procedures to prevent abuse, neglect, and exploitation of residents, specifically in the case of a resident with a history of aggressive behavior. This resident, who has diagnoses including hemiplegia, mood disorder, major depressive disorder with psychotic symptoms, and intermittent explosive disorder, exhibited repeated verbal aggression towards staff and other residents. Despite these behaviors being documented in the resident's care plan, the facility did not take adequate measures to ensure the safety of other residents, leading to an incident where the resident verbally harassed another resident and threw an object, resulting in a physical altercation. Interviews and record reviews revealed that the facility's staff, including the Director of Nursing (DON) and Assistant Director of Nursing (ADN), were aware of the resident's aggressive behavior but did not report the incidents to the state as required. The staff's response to the altercation was inadequate, as they failed to prevent the escalation of the situation and did not ensure the safety of all residents involved. Additionally, the facility's policy for aggressive residents was not effectively implemented, as staff were only instructed to redirect the aggressive resident without further intervention. The facility's failure to address the aggressive behavior of the resident and protect other residents from harm was further highlighted during a resident council meeting, where multiple residents expressed fear of the aggressive resident. The facility's inaction and lack of proper reporting and intervention procedures put all residents at risk of abuse, as the staff did not follow the established policies for managing resident-to-resident altercations.
Removal Plan
- Resident #52 was sent to psych hospital for inpatient stay by an emergency detention warrant obtained through the county judges office.
- Abuse policies were reviewed by both corporate nurses.
- The Administrator and DON were re-in serviced by the corporate nurse and COO.
- All residents were reviewed by the SS and marketing director, and no one is exhibiting aggressive behaviors at this time.
- Abuse investigation procedure and documentation process were reviewed by both corporate nurses.
- The administrator and designees educated all staff on facility abuse policies.
- The administrator and designees educated all staff on abuse prevention and reporting.
- The Social Services Director began discussing facility abuse policies with residents and families at the initial care plan conference for all new residents that enter the facility.
- New staff will be educated and trained on facility abuse policies upon hire during general orientation.
- Agency staff will be educated and trained on facility abuse policies prior to starting shift.
- Abuse Prevention and Response policies made available for review at all times.
- Confirmation that Resident was discharged to Ocean' behavioral hospital.
- Audit of Policies to show they were reviewed by the corporate nurse and the administrative team were educated.
- In-services to Staff on Abuse Neglect were started and per audit completed all staff scheduled have completed the training. All administrative staff completed the training, plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations.
- In-services to Nursing staff and IDT team on Care plans and documentation were started and per audit all nursing staff on duty and all IDT team members have completed training, Plan is for remaining staff and PRNs to complete training prior to working the next shift. A text was sent out to all employees with expectations.
- Per interview with administrator, 1:1's will be determined by himself and the DON and in services will be done at that time to address the resident's needs.
- Interviews with staff members on duty revealed they have all had training and all were able to verbalize the training and the process for reporting and managing resident to resident aggression.
Failure to Implement Comprehensive Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included interventions to ensure safety from the resident's aggressive physical and verbal behaviors. The resident, a male with a history of hemiplegia, mood disorder, major depressive disorder with psychotic symptoms, and intermittent explosive disorder, exhibited repeated instances of verbal aggression towards staff and other residents. Despite these behaviors being documented over several months, the facility did not have a behavior modification plan in place for the resident, nor were there any special interventions to manage his aggressive behaviors. On one occasion, the resident was involved in an altercation with another resident, which was witnessed by several staff members and residents. The incident report indicated that the resident verbally harassed another resident and threw an object, leading to a physical confrontation. The facility's social worker and assistant director of nursing (ADN) were aware of the resident's behaviors and the altercation, but no immediate actions were taken to address the situation or report it as required by the facility's policies. The facility's failure to address the resident's aggressive behaviors and implement a comprehensive care plan put other residents at risk. During a resident council meeting, several residents expressed fear of the aggressive resident, with one resident stating they carried a cane for protection. The facility's social worker admitted that interventions to redirect the resident's behavior were often unsuccessful, and the ADN acknowledged the difficulty in managing the resident's case, expressing uncertainty about what actions to take until a more appropriate placement could be found.
Medication Administration Omissions
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, resulting in the omission of prescribed medications. Resident #45, a male with type 2 diabetes, hypertension, and heart failure, did not receive his prescribed Diltiazem, Gabapentin, and Amiodarone on multiple occasions in August 2024. The medication administration records (MAR) showed these medications were not administered, and no reasons were documented for the omissions, despite other medications being given on the same days. Resident #25, diagnosed with schizophrenia, bipolar disorder, and hypertension, also experienced medication omissions. His MAR indicated that Hydroxyzine Pamoate, Abilify, Benztropine Mesylate, Divalproex Sodium ER, and Gabapentin were not administered on several dates in August 2024. Again, no reasons were documented for these omissions, and other medications were administered, suggesting the resident was present at the facility. Resident #10, with conditions including hypertension, glaucoma, and gastroesophageal reflux disease, did not receive his prescribed Rhopressa Ophthalmic Solution, Simbrinza Suspension, Tamsulosin HCl, and Mylanta Suspension on various dates in August 2024. The MAR reflected these omissions without documented reasons, while other medications were administered. Interviews with the MD and DON highlighted concerns about the importance of adhering to medication orders and the potential impact of persistent omissions on therapeutic levels. The DON acknowledged the issue but was uncertain if the omissions were due to administration errors or documentation lapses.
Failure to Report Resident Altercation in a Timely Manner
Penalty
Summary
The facility failed to report an alleged resident-to-resident altercation involving two residents to the administrator or abuse coordinator and to the Texas Health and Human Services Commission (THHSC) within the required 2-hour period. Resident #52, a male with a history of hemiplegia, mood disorder, major depressive disorder with psychotic symptoms, and intermittent explosive disorder, was involved in an altercation with Resident #42, who has Alzheimer's disease, a history of stroke, and an anxiety disorder. The incident occurred after Resident #52 verbally harassed Resident #42, leading to a physical confrontation where Resident #42 attempted to hit Resident #52 with a chair. The incident was witnessed by staff and other residents, and it was reported that Resident #52 was the instigator. Despite the altercation, the facility's administrator did not report the incident to the state agency, as he believed there was no intent to harm and was unsure if it qualified as reportable. The Director of Nursing (DON) was aware of the incident but did not confirm if it was reported, as the responsibility lay with the administrator. The facility's policy requires all alleged violations involving abuse to be reported immediately, but this was not adhered to in this case. The facility's failure to report the incident promptly could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. The facility's policy on abuse prevention and resident-to-resident altercations emphasizes the importance of immediate reporting to ensure resident safety, but this protocol was not followed. The administrator's misunderstanding of the reporting requirements and the lack of immediate action contributed to the deficiency.
Infection Control Deficiency: Unsanitized Blood Pressure Monitor
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a resident diagnosed with type 2 diabetes, hypertension, acquired absence of both legs above the knee, and heart failure. The resident's care plan included monitoring for complications related to atrial fibrillation and hypertension. During an observation, a medical assistant (MA) did not sanitize a wrist blood pressure monitor before using it on the resident, which could lead to the transmission of infections. The MA admitted to forgetting to sanitize the equipment due to focusing on medication administration, despite being aware of the importance of sanitizing medical equipment. The Director of Nursing (DON) confirmed that the facility's policy required the sanitization of medical equipment, including blood pressure monitors, to prevent the spread of infectious diseases. However, a review of in-service records revealed that no training sessions on the disinfection of medical equipment had been conducted between April and July 2024. The facility's policy, revised in June 2011, outlined the necessity for cleaning and disinfecting reusable items between residents, but this protocol was not followed in this instance.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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