Woodland Springs Nursing Center

Penalty

Inspection fine: $12,428

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store food in accordance with professional standards for food service safety in its only kitchen. During observation of the dry storage area, three bins of dry beans were found with only one date on the label and no indication of what the items were, when they were placed in the container, or when they should be used by. Several opened and resealed bags of cereal also lacked dates showing when they were opened and when they should be discarded, and two to three bags of pasta noodles were not labeled and dated properly. In the walk-in refrigerator, a container labeled Zuc/Ham with a use-by date of 11/15/2025 was observed stored with other items. There were also packages of celery, carrots, and beans with no dates on them. The Dietary Manager stated he had recently started in the position, had not received information from the previous manager, and was trying to get things in order. The facility policy required dry foods stored in bins to be labeled and dated and refrigerated foods to be covered, labeled, dated, and monitored for use-by dates.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective pest control program for three halls, including halls 100, 200, and 300. During observations, multiple wall-mounted hand sanitizer automatic disbursement units had dead insects in the catchment trays below them, including four dead insects across from room [ROOM NUMBER]A, a dead fly and two other dead insects next to room [ROOM NUMBER], two dead insects next to room [ROOM NUMBER], one dead insect near the 200-hall shower room, one dead insect on the 300-hall in front of the shower room, 30 plus dead insects next to room [ROOM NUMBER], nine dead insects next to room [ROOM NUMBER], and six dead insects next to room [ROOM NUMBER]. In room 326, two live gnats were observed flying around while CNA C was changing sheets, and she stated she had also seen gnats in resident rooms around the facility. Residents #1 and #3 were in the room but were unable to respond due to severe cognitive impairment. Staff interviews showed the Housekeeping Supervisor was not aware of the dead insects in the sanitizer trays and stated staff were supposed to document insect sightings in the pest control logbook behind the nursing station. The Maintenance Supervisor stated he and his assistant refilled the sanitizer units, noticed the dead insects, and would tell housekeeping to clean them; he also stated pest control visited monthly and could be called more often if needed. The ADON stated nursing staff used the hand sanitizers every day but had not reported the dead insects, and the ADM stated housekeeping was responsible for cleaning the units. Record review found no entries in the pest sighting logbook from 06/01/2025 to 12/03/2025, one maintenance log entry dated 07/12/2025 referencing flies and gnats at the end of the 300-Hall, and no relevant resident grievances about insects. The facility policy stated it maintained an ongoing pest control program for insects and rodents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate supervision and assistance devices to prevent accidents for four residents who used wheelchairs for locomotion. Resident #41 had diagnoses including dementia, hypertension, and limited range of motion in the lower extremities, and his MDS reflected severe cognitive impairment and inability to make decisions. During observation, he was seated in his wheelchair in the main dining room, and both armrests were cracked with foam exposed. He stated the wheelchair arms were rough and that he did not know who to tell about the condition of the wheelchair. Resident #90 had diagnoses including mood disorder, hypertension, and limited range of motion in the lower extremities, and his MDS reflected moderate cognitive impairment and inability to make decisions. He was observed seated in his wheelchair in the main dining room with the left armrest cracked and foam exposed. He stated he was happy with the wheelchair and did not know who to tell about the armrest, though he thought it could be fixed so the wheelchair would look better. Resident #91 had diagnoses including cerebral palsy and anxiety, and her MDS reflected that she was cognitively alert and able to make decisions for herself. She was observed seated in her wheelchair in the main dining room with the left armrest missing and the right armrest cracked with exposed foam; she stated the missing armrest was cold and that she had not told anyone about it. Resident #12 had diagnoses including generalized muscle weakness and depression, and her MDS reflected severe cognitive impairment and inability to make decisions. She was observed seated in her wheelchair in the main dining room with the right armrest missing and dried white substance on the back of the wheelchair. CNA B stated staff were to report broken wheelchair equipment to the Director of Rehabilitation, but she was unaware of any log or system for reporting broken equipment and had not reported any recent issues. The Director of Rehabilitation stated staff reported equipment problems directly to rehab, rehab repaired wheelchairs, maintenance had nothing to do with wheelchair repair, and there was no log or special rounds to identify wheelchairs needing repair. The Administrator stated he had nothing to do with wheelchair repair, that he informed therapy if he saw worn wheelchairs, and that there was no system for communication concerning wheelchair repair. The facility policy stated assistive devices and equipment would be maintained on schedule and defective or worn devices would be discarded or repaired.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a safe, functional, sanitary, and comfortable environment on Hall 300, with bathroom floors and fixtures in poor repair in rooms 350, 352, 354, and 355. During observation, the bathroom for Room 350 had a center drain pushed through the tile about 1 inch, with a 7-inch crescent of missing tiles around the drain, remaining tiles connected to the drain pipe, sharp tile edges, and a raised area about 3/4 inch high. The bathroom in another room had missing floor tiles exposing bare concrete, separated wall tiles behind the toilet, and discoloration resembling rust. Another bathroom was missing a toilet paper bracket and had red staining along the floor and wall edge, and the bathroom in Room 355 had a missing section of floor tile exposing bare concrete.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat a resident with respect and dignity when CNA A stood over Resident #38 while assisting him with meals in the dining room. Resident #38 was a [AGE]-year-old male with a BIMS score of 00 and diagnoses including Alzheimer's disease, dementia, anxiety disorder, and mood disorder. His quarterly MDS showed he required partial/moderate assistance with eating and had a mechanically altered therapeutic diet with swallowing issues. His care plan identified difficulty swallowing related to dementia and Alzheimer's disease and directed that he receive set-up assistance from one staff member for eating and monitoring of nutritional intake. During observation, CNA A was seen standing next to Resident #38 while assisting him with breakfast and later lunch. At breakfast, CNA A held a spoon with food and told the resident he needed to eat and try a few more bites; the resident did not respond verbally and only opened his mouth to take the bite. At lunch, CNA A again stood next to him and stated she was going to try to get him to take a couple more bites. In interview, CNA A stated staff were supposed to sit down to feed residents, that she knew she should have gotten a chair, and that standing over the resident while assisting him to eat was against residents' rights and a dignity issue. The DON stated staff should be seated at eye level when assisting residents to eat and that feeding residents standing up was a dignity issue. The facility policy also stated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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 staff member and one resident reviewed for infection control procedures. During observation of incontinent care for a severely cognitively impaired resident with diagnoses including Alzheimer's disease, anorexia, and dementia, the CNA entered the room after using hand gel in the hallway and putting on gloves, then performed perineal care while the resident lay in bed and did not respond to questions during the observation. While cleaning the resident after he had smeared bowel movement on his pants and brief, the CNA used multiple wipes and repositioned the resident, but then fastened the clean brief without changing her soiled gloves or washing her hands. She continued the care with the same gloves, opened drawers and touched clothing while looking for clean pants, then finished the care, discarded her gloves, gathered the trash bag, and left the room without washing her hands or using hand sanitizer. The CNA stated she knew she did not change her gloves or wash her hands and said she had been trained in infection control, changing gloves, and handwashing. The DON stated staff should change gloves from dirty to clean and wash hands or use hand sanitizer during incontinent care, and the facility policy required hand hygiene before and after resident contact, after glove removal, and when moving from a soiled body site to a clean body site on the same resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $29,85814 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $12,428

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $28,677

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $28,677

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $28,677

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $28,677

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $28,677

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

Inspection fine: $28,677

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.