Citations in Texas
Statistics, citations and compliance trends for long-term care facilities in Texas.
Statistics for Texas (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in Texas
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Latest Citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Some of the Latest Corrective Actions taken by Facilities in Texas
- Revised and reinforced timely pressure-injury risk identification on admission and with condition change using the 24-hour report, with DON/MDS reviewing every admission and condition change to ensure issues were identified and addressed (K - F0686 - TX)
- Implemented weekly skin assessments with leadership validation by having charge nurses complete weekly skin assessments and ADON audit after completion (K - F0686 - TX)
- Implemented a physician-notification audit process for skin issues by requiring charge nurses to notify the physician for identified skin issues and having the DON audit physician notification through progress notes (K - F0686 - TX)
- Implemented a wound-consultant follow-up process by having the ADON round with the wound physician and implement orders and new treatments (K - F0686 - TX)
- Implemented a care-plan revision validation process by requiring charge nurse/ADON/MDS to revise care plans following required change and having the DON audit care plan changes (K - F0686 - TX)
- Implemented a heel offloading monitoring system by assigning charge nurses/CNAs to offload heels in bed, using an ADON/DON monitoring sheet for validation, and maintaining a DON list of residents requiring heel offloading (K - F0686 - TX)
- Re-educated licensed nurses and CNAs with a post-test on pressure-injury prevention covering risk recognition, repositioning/offloading techniques, immediate reporting of skin changes, and documentation of skin checks on skin observation sheets (with administrator tracking attendance and post-tests) (K - F0686 - TX)
- Implemented ongoing DON/ADON monitoring and audits for pressure-injury prevention and wound care compliance including audits of residents with pressure injuries/at risk for breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates, with immediate correction of negative findings and reporting of trends to QAPI (K - F0686 - TX)
- Implemented DON/designee daily spot checks of wound treatments to verify ordered wound care was completed and documented (K - F0686 - TX)
- Implemented a daily wound care assignment sheet to ensure accountability for completing ordered wound treatments (K - F0686 - TX)
- Re-educated licensed nurses on the wound care policy including treatment frequency, dressing type, documentation requirements, and expectations for notifying the physician of wound-condition changes (K - F0686 - TX)
- Reviewed audit results in QAPI meetings to support ongoing oversight of wound-treatment compliance (K - F0686 - TX)
- Amended wound-treatment orders to require pain evaluation prior to treatments and medication if indicated to prevent unmanaged pain during wound care (J - F0697 - TX)
- Re-educated licensed nurses on pain assessment and management including change in condition, administering pain medications, and the pain-clinical protocol (including anticipating increased pain with wound care, ambulation, repositioning, and using the critical element pathway for pain recognition/management) (J - F0697 - TX)
- Re-educated non-licensed nursing staff on recognizing and reporting pain changes using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse (J - F0697 - TX)
- Validated staff education via quiz and acknowledgement covering recognition of changes in condition, notification procedures, and pain assessment/management (J - F0697 - TX)
- Implemented ongoing change-in-condition/pain assessment audits by reviewing the 24-hour summary report and nurse progress notes to ensure changes were reported to the provider and documented and that pain assessments were completed prior to treatments, with audit results reviewed in IDT/QAPI meetings and issues addressed immediately (J - F0697 - TX)
- Re-educated licensed nurses, MDS staff, and IDT members on comprehensive person-centered care planning requirements including timely care plan revision after new wounds/condition changes, measurable objectives and individualized interventions, and communication of updated interventions to direct care staff via Kardex/POC system and documentation of care plan review/implementation (J - F0656 - TX)
- Implemented an expectation for immediate care-plan revision when issues were identified by requiring the ADON responsible for wound care to revise care plans as soon as an issue was identified and having the DON validate care plan revisions during morning meeting (J - F0656 - TX)
- Established ongoing monitoring/audits for timely care-plan updates by having DON/ADON/MDS Coordinator audit residents with new wounds, current pressure injuries, significant changes in condition, and identified skin risk factors to verify care plans were revised timely and interventions were individualized and implemented, with results brought to QAPI for trend analysis and additional corrective action (J - F0656 - TX)
Failure to Implement Heel Offloading, Repositioning, and Skin Assessment Leading to Stage 4 Heel Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer prevention and treatment services, consistent with professional standards, for a severely cognitively impaired, bedbound resident who was always incontinent and fully dependent on staff for mobility and transfers. On admission from the hospital, the resident had no heel wounds but did have a history of skin issues on the buttocks and peri-area, and the hospital’s wound care documentation included a prevention plan directing that the heels be offloaded using heel protector boots or pillows. The resident’s care plan identified her as at risk for pressure ulcers, with goals to prevent breakdown and interventions such as frequent incontinence care, bathing per schedule, weekly skin checks, and nutritional support, but it did not include specific interventions for heel offloading or repositioning every two hours. The record shows that the facility did not consistently assess and monitor the resident’s skin condition as ordered. A Braden Scale assessment was completed once, rating the resident as low risk, and no further Braden assessments were found. Physician orders dated 12/31/2025 required head-to-toe skin assessments and documentation of any changes in skin integrity on specified days, with physician notification of changes, yet there was no evidence these assessments were performed on multiple ordered dates. The EHR contained no documented Skilled Observation Notes used as skin assessments for a prolonged period, and later Skilled Observation Notes uniformly described the skin as intact with no notable changes, despite the subsequent development of heel blisters and pressure injuries. The DON later acknowledged that skin assessments were not documented in the EHR and that only changes in skin integrity were recorded in progress notes. When blisters on both heels were identified on 02/09/2026, the nurse practitioner ordered daily skin prep to the bilateral heel blisters and offloading of both heels with heel protectors while in bed. However, the MAR/TAR showed multiple shifts where heel offloading was not documented as provided, and there were several days when the ordered skin prep was not documented as applied. CNAs reported that heel protectors were sometimes removed by nurses, that the resident sometimes refused them, and that bandages were often not changed over weekends. The wound care physician, who began seeing the resident after the heel wounds developed, noted that the resident was sometimes not wearing heel protectors and attributed the wound development to immobility and general decline. By 03/10/2026, the resident’s right heel remained an unstageable deep tissue injury and the left heel had progressed to a Stage 4 pressure wound. The facility’s own skin integrity policy required repositioning at-risk residents at least every two hours and use of pillows or wedges to keep bony prominences from direct contact, but the DON later confirmed that the resident’s care plan lacked interventions for heel offloading or repositioning, and there were no orders for an air pressure mattress.
Removal Plan
- DON/ADON conducted an audit of all current residents to identify those at risk for pressure injuries (limited mobility, dependence for repositioning, malnutrition, existing wounds, recent decline); screened all residents and identified at-risk residents.
- Completed updated skin assessments on all residents and filed them in the medical record under the document tab.
- Verified pressure-relieving devices for identified at-risk residents (physician order as required, care planned, and device in place).
- Reviewed treatment orders for all at-risk residents to ensure treatment orders exist for all identified skin issues; notify MD to obtain orders when missing.
- Reviewed nutritional status for all at-risk residents to ensure nutrition assessment completed; obtain MD orders as needed; update care plan; RD review.
- Reviewed and updated care plans for all at-risk residents to address skin concerns including wounds, treatment, pressure-relieving devices, repositioning, and nutrition.
- Revised and reinforced the process for timely risk identification on admission and with condition change using the 24-hour report; DON/MDS to review every admission and condition change to ensure conditions are identified and addressed.
- Implemented weekly skin assessments completed by charge nurse with ADON auditing after completion.
- Implemented physician notification process: charge nurse to notify physician of identified skin issues; DON to audit physician notification through progress notes.
- Implemented wound consultant follow-up process: ADON to round with wound physician; ADON to implement orders and new treatments.
- Implemented care plan revision process: charge nurse/ADON/MDS to revise care plan following required change; DON to audit care plan changes.
- Implemented heel offloading process for applicable residents: charge nurse/CNAs responsible for offloading heels while residents are in bed; ADON/DON to validate using a monitoring sheet; DON to develop and maintain a list of residents requiring heel offloading.
- Re-educated licensed nurses and CNAs with post-test on pressure injury risk recognition, repositioning and offloading techniques, immediate reporting of skin changes, and documentation of skin checks on skin observation sheets; administrator to track attendance and post-tests.
- Implemented ongoing monitoring and audits by DON/ADON of residents with current pressure injuries, residents at risk for skin breakdown, repositioning documentation, weekly skin assessments, wound treatment compliance, and care plan updates.
- Correct negative audit findings immediately, including staff counseling and re-education, resident reassessment, physician notification, and care plan revision as indicated.
- Report audit findings and trends to the QAPI Committee for ongoing review and additional action if needed.
- Notified the Medical Director of the IJ and discussed and obtained approval of the plan of removal.
Failure to Implement Abuse Reporting and Protection Policies for Resident-to-Resident Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse prohibition policies and procedures to identify, report, and protect residents from abuse, specifically in relation to two cognitively intact residents who were in a relationship and shared a room. The facility’s Abuse Prohibition Policy defined abuse to include physical, mental, and verbal abuse, and required that any allegation of abuse made by residents, staff, or visitors be reported immediately to the Abuse Coordinator and investigated. The policy also required immediate protection of residents, monitoring of staff and resident behaviors to identify potential abuse, and specific steps for resident‑to‑resident incidents, including separating residents, assessing for injury, notifying the physician and family, completing incident reports, and contacting the Abuse Coordinator. One resident, an adult male with paraplegia, major depressive disorder, and anxiety disorder, and another resident, an adult female with cerebral infarction, severe visual impairment, bipolar disorder, and anxiety disorder, both had intact cognition with BIMS scores of 15/15 and had requested to room together. The male resident had care plan entries documenting a history and potential for verbally aggressive and accusatory behavior toward staff and residents, and episodes of verbal aggression/irritability when care for his girlfriend/roommate was not provided immediately. On one occasion, nursing notes documented that the female resident reported crying and being upset because her boyfriend yelled at and belittled her in front of others, and she expressed a desire to move out of the shared room. The LVN reported this to the social worker, who spoke with the resident; the resident later recanted and stated she loved him, and the male resident stated he had only told her to tell the nurse about her stomach pain. The Administrator was aware of this incident but, based on the recantation, did not consider it reportable and did not treat it as an abuse allegation under the policy. On a subsequent date, a CNA completed a written witness statement indicating she had observed the male resident yell at the female resident and call her a derogatory term, specifically “[f‑ing retard].” The CNA believed the Abuse Coordinator would see this in the statement, but the Administrator later stated she had not seen that portion of the statement. The Administrator acknowledged that such language would constitute verbal abuse and would be reportable to the state agency, yet the incident was not reported to the Abuse Coordinator or to the state agency as required by policy. Later, both a CNA and a medication aide witnessed the male resident pushing the female resident in her wheelchair and shoving her into trash and dirty linen barrels in the hallway. Both staff members stated they did not consider this to be abuse and therefore did not report it to the Administrator or Abuse Coordinator. The Administrator reported she was unaware of this physical incident until informed by the CNA shortly before the surveyor interview and acknowledged that it could be considered physical abuse and would be reportable. These failures to recognize, report, and respond to resident‑to‑resident verbal and physical abuse incidents, despite clear policy requirements and prior knowledge of the male resident’s behavioral history, led to the cited deficiency and the identification of an Immediate Jeopardy situation.
Removal Plan
- Attempted to separate Residents #14 and #55; both residents refused a room change.
- Initiated 1:1 monitoring for Resident #14 due to refusal to change rooms; monitoring to continue until risk is fully mitigated and IDT determines supervision can be safely reduced.
- Reviewed and updated care plans for Residents #14 and #55 to reflect supervision needs and behavioral concerns.
- Provided education to Residents #14 and #55 regarding personal safety and boundaries, risks associated with unsupervised interactions, and the facility’s responsibility to intervene when safety concerns arise; ongoing reinforcement planned.
- Completed a trauma-informed psychosocial assessment for Resident #55 to evaluate for emotional distress, coercion, or unmet needs; continued monitoring initiated.
- Assessed both residents for physical and psychosocial harm; no additional injury identified.
- Completed life satisfaction rounds to ensure no other residents were negatively affected; no negative findings.
- Notified the Medical Director regarding the alleged failure to follow abuse policies and procedures.
- In-serviced Administrator and DON on abuse policy and reporting procedures; competency validated via quiz.
- In-serviced facility staff on abuse policy and reporting procedures; competency validated via quiz; staff not allowed to work next scheduled shift until training completed.
- Incorporated the abuse training material into new hire orientation and ongoing.
- Audited incident reports for the last 3 months to ensure no other reportable incidents were missed; no negative findings.
- Audited grievances for the last 3 months to ensure no other reportable issues were missed; no negative findings.
- Implemented a protocol for resident-to-resident abuse when both residents refuse room change: immediate enhanced supervision, revise care plans, complete IDT review, assess capacity and risks, involve physician and responsible parties, and consider alternative interventions; ongoing reassessment until risk is fully mitigated.
- Established monitoring/QA process: Administrator/DON daily review of all incidents, grievances, and behavior notes, then weekly, then monthly; random staff interviews to validate understanding of abuse reporting; QAPI Committee review; immediate re-education and disciplinary action as indicated.
Failure to Implement Antibiotic and Diabetes Management Orders Resulting in Significant Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to antibiotic therapy and blood glucose management. An [AGE]-year-old female resident with diagnoses including vesicointestinal fistula, hypertension, type 2 diabetes mellitus with hyperglycemia, and early-onset Alzheimer’s disease was admitted following hospitalization and surgery for colostomy placement. Her physician orders included long-acting insulin (Semglee), sliding-scale insulin (NovoLOG), blood glucose monitoring before meals and at bedtime with provider notification for values <60 or >400 mg/dL, a continuous glucose monitoring (CGM) sensor (FreeStyle Libre 2), and prophylactic antibiotics (Ciprofloxacin and Metronidazole) along with other medications. Record review showed that from admission through several days, the antibiotic orders were not transcribed onto the MAR and no doses were administered, and the CGM sensor was not implemented. During the same period, the resident’s blood glucose readings were repeatedly and significantly elevated, with documented values of 512 mg/dL, 482 mg/dL, 459 mg/dL, and 492 mg/dL. Despite an order to notify the provider if blood glucose was <60 or >400 mg/dL, there was no evidence in the record that the physician was notified of these out-of-parameter results. Additionally, there was no documentation of nighttime blood glucose checks, even though orders required blood glucose monitoring before meals and at bedtime. Staff interviews revealed that some medications, including long-acting insulin, were not immediately available or did not appear on the MAR, and that staff relied on sliding-scale insulin without obtaining new physician orders or consistently documenting provider notifications. Nursing staff also reported communication delays with on-call providers and PACE, and acknowledged that no new orders were obtained despite persistently elevated blood glucose levels. Multiple interviews with PACE clinicians and facility leadership confirmed that the ordered prophylactic antibiotics and CGM device were not implemented as prescribed, and that providers were not notified of missed medications or abnormal blood glucose values. PACE staff stated that antibiotics (Ciprofloxacin and Metronidazole), probiotics, insulin, and other routine medications had been ordered upon discharge from the hospital, but the facility failed to administer the antibiotics and did not apply the ordered glucose monitoring sensor. The DON and ADON acknowledged that medication reconciliation was not completed upon admission for this resident, that there was no standardized process to ensure baseline blood glucose assessment or consistent review of hospital records, and that oversight of admission orders and blood glucose monitoring was inconsistent. The resident ultimately required transfer to the hospital, where she was admitted to the ICU with DKA and septic shock, and hospital staff documented hyperglycemia, UTI, markedly elevated WBC, and the need for sepsis protocol, IV antibiotics, and insulin drip. Facility policies in place at the time required that blood glucose monitoring be completed per provider orders, that physicians be notified when glucose results were outside ordered parameters, and that insulin be administered only upon a physician’s order. The physician orders policy required that all physician orders be valid, safe, and clarified if unclear prior to implementation. Interviews with the DON, ADON, and other staff indicated that these policies were not consistently followed: there was no daily process to review medications for accuracy or completeness, medication pass audits were intermittent, and staff did not consistently notify physicians when medications were unavailable or when ordered treatments (such as the CGM sensor) could not be implemented. Communication gaps with external providers, particularly PACE, and lack of a standardized admission and reconciliation process contributed to the failure to transcribe and administer antibiotics, to perform ordered bedtime blood glucose checks, to notify providers of critical glucose values, and to implement the ordered continuous glucose monitoring device for this resident.
Removal Plan
- Conducted mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtained verbal and written confirmation of understanding; implemented ongoing competency checks; incorporated training and written competencies into new-hire orientation; made policies readily available via CNO/ACNO/Administrator.
- Reviewed the resident’s hospitalization status with the hospital and confirmed ICU admission for DKA and septic shock; confirmed the resident did not return to the facility.
- Held nurse meetings with all nursing staff who cared for the resident to review specific failures, including missing bedtime blood glucose checks, failure to notify the provider of blood glucose greater than 400, failure to implement CGM, and failure to communicate about unavailable supplies.
- Provided mandatory re-education for all licensed nursing staff on the Blood Glucose Monitoring Policy and physician notification requirements, emphasizing obtaining blood glucose exactly as ordered, immediately notifying the provider when out of parameters, notifying physician/CNO/ACNO when supplies or equipment are unavailable, and clarifying unclear or unimplementable orders prior to implementation.
- Established a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes, out-of-parameter lab or glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-serviced RNs/LVNs on the protocol.
- Implemented a redundant notification system requiring that when any blood glucose result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time/person contacted and response received; in-serviced RNs/LVNs on the system.
- Conducted a comprehensive review to identify other residents at risk for failures in physician notification, blood glucose monitoring, or implementation of physician orders.
- Reviewed all current residents to identify those with active blood glucose monitoring orders.
- Completed a chart audit of residents with blood glucose monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely provider notification; reported issues to physicians and obtained clarifying or new orders; initiated continued daily monitoring by CNO/ACNO/nurse manager.
- Reviewed all current residents to identify those with orders for continuous monitoring devices or specialized medical equipment; verified implementation and identified no issues.
Failure to Notify Physician of Critically High Blood Glucose and Perform Ordered Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician when a resident’s blood glucose (BG) levels exceeded ordered parameters and to consistently perform ordered BG monitoring. An older female resident with type 2 DM with hyperglycemia, early-onset Alzheimer’s disease, hypertension, and a vesicointestinal fistula was admitted with physician orders for BG monitoring before meals and at bedtime, with instructions to notify the provider if BG was less than 60 mg/dL or greater than 400 mg/dL. Review of the order summary and admitting physician orders confirmed these parameters. However, record review showed multiple BG readings well above 400 mg/dL over several days without documented physician notification, and there was no evidence that bedtime BG checks were performed as ordered. Specifically, the resident’s record showed BG values of 512 mg/dL on one day, 482 mg/dL on the next day, 459 mg/dL on a later day, and 492 mg/dL on another day, all documented without any corresponding evidence that the physician was notified, despite the explicit order to notify for BG values greater than 400 mg/dL. The medication administration record and BG logs also showed no documented nighttime BG checks, even though the orders required monitoring before meals and at bedtime. The resident’s care plan identified insulin therapy and BG monitoring with goals for BG within normal limits and interventions including monitoring, documenting, and reporting adverse effects of insulin therapy and following hypo/hyperglycemia protocols, but the actual documentation did not reflect adherence to these monitoring and notification requirements. Interviews with facility staff and external PACE providers further described inconsistent communication and incomplete implementation of ordered treatments. The NP from PACE stated she was not notified that the resident’s BG had been over 400 mg/dL and that, upon later review, insulin and BG monitoring orders had been provided but were not implemented as ordered by the facility. A PACE RN reported that he was notified of elevated BG and gave instructions for additional sliding scale insulin and close monitoring, and that long-acting insulin should have continued, but there was no documentation in the facility record to support these communications or new orders. Facility nurses described elevated BG readings in the 400–500 mg/dL range, sometimes unreadable on the glucometer, ongoing use of sliding scale insulin, delays or gaps in admission order processing, and uncertainty about whether antibiotics ordered were administered. The resident was ultimately transferred to the hospital with hyperglycemia and UTI and was admitted to the ICU for DKA and septic shock. The facility’s own policy on blood glucose monitoring required following physician notification parameters when results were outside ordered ranges, but the documented practice for this resident did not meet those requirements, leading surveyors to identify an Immediate Jeopardy situation related to failure to notify the physician of out-of-parameter BG results and failure to carry out ordered BG monitoring. Additional interviews with leadership and other staff highlighted that medication reconciliation and admission review processes were inconsistent and that there was no standardized daily review of medications or BG monitoring for accuracy and completeness. The ADON and DON acknowledged that medication pass audits were not done daily, that there was no consistent daily process to review medications, and that communication with external providers such as PACE was often inconsistent. The DON and Medical Director described expectations that urgent situations be evaluated immediately and that orders be implemented without delay, but also acknowledged that residents with worsening conditions were sometimes transferred to the hospital rather than having earlier interventions. The MDS nurse stated that she did not recall seeing documentation regarding antibiotic therapy or BG monitoring for this resident and that follow-up on such treatments depended on nursing processes. The PACE NP later stated that prophylactic antibiotics and insulin management had been ordered but not administered, and that the resident’s decline, including DKA and sepsis, was attributed in part to missed medications and lack of timely intervention. These documented failures in BG monitoring, physician notification, and implementation of ordered treatments formed the basis of the cited deficiency.
Removal Plan
- Conduct mandatory in-service education for licensed nursing staff and admission staff on new policies and procedures; obtain verbal and written confirmation of understanding; implement ongoing competency checks; ensure policies are readily available from the CNO/ACNO; incorporate training and written competencies for new hires upon hire.
- Review Resident #2’s current hospitalization status with the hospital and confirm ICU admission for DKA and septic shock; confirm resident did not return to the facility.
- Hold nurse meetings with all nursing staff who cared for Resident #2 to review specific failures (missing bedtime BG checks, failure to notify provider of BG >400, failure to administer continuous glucose monitoring device, failure to communicate about unavailable supplies).
- Provide mandatory re-education for all licensed nursing staff (RNs/LPNs) emphasizing: obtaining BG readings exactly as ordered; immediate provider notification when results are outside parameters; immediate notification to physician/CNO/ACNO when ordered supplies/equipment are unavailable; and clarifying unclear or unimplementable orders prior to implementation.
- Establish a communication protocol with the local PACE organization requiring nursing staff to contact PACE providers immediately for clinical concerns, significant changes in condition, out-of-parameter lab/glucose values, and inability to implement orders due to unavailable supplies or unclear orders; in-service RNs/LVNs on the protocol.
- Implement a redundant notification system requiring that when any BG result is outside ordered parameters, the nurse must immediately notify the physician/PACE provider and document date/time, person contacted, and response received; in-service RNs/LVNs on the system.
- Conduct a facility-wide review to identify residents at risk for similar failures related to physician notification, BG monitoring, or implementation of orders.
- Review all current residents to identify those with active BG monitoring orders.
- Complete a comprehensive chart audit of residents with BG monitoring orders to verify monitoring was performed as ordered, identify out-of-parameter results, and confirm timely documented provider notification; report identified issues to physicians and obtain clarifying or new orders as needed; initiate continued daily monitoring by CNO/ACNO/nurse manager.
- Conduct a Root Cause Analysis (RCA) including staff interviews and fishbone analysis to identify underlying causes of the IJ event.
- Revise the Blood Glucose Monitoring Policy to require immediate physician notification for out-of-parameter BG results and to require documentation of the exact time of the out-of-parameter result, exact time of provider notification, name of person contacted, and provider response or orders received; educate staff on the revised policy.
Failure to Assess and Manage Abnormal Catheter Urine Leading to Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with an indwelling urinary catheter received appropriate assessment, intervention, and catheter management in response to persistent abnormal urine characteristics and signs of possible infection. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an indwelling catheter, colostomy, and feeding tube, and was dependent on staff for all ADLs. Her care plan identified her as having a catheter, being at risk for UTIs, and having frequent UTIs, with specific interventions to monitor urine for color, sediment, odor, amount, and to report abnormalities such as blood-tinged urine, cloudiness, no output, deepening of urine color, and other signs of UTI to the physician. Physician orders directed that the Foley catheter and drainage bag be changed PRN for signs of infection, obstruction, or compromise of the closed system. On one date, an LVN documented that the resident’s catheter was draining blood-tinged urine, that her blood pressure was low, and that the physician was notified, resulting in orders for a UA and IV fluids. The resident later refused IV fluids, and a UA collected showed blood, protein, mucus, and WBC clumps, with blood and protein flagged as critical, but there were no documented follow-up orders or interventions after these results. The NP documented dark orange/red urine and noted a contaminated UA with mixed microbial growth, ordering a repeat UA and labs, and recorded that the resident had refused IV fluids. The NP stated that dark orange urine could be normal if related to minor bleeding from catheter movement but that dark brown/black urine would not be normal and should be reported; she also stated that whenever a UA was ordered, staff were supposed to change the catheter. The electronic record showed the resident’s indwelling catheter was last changed several months earlier, with no documentation of catheter changes, urine color/characteristics, or change in condition from that date through the days immediately preceding the resident’s transfer to the hospital. Multiple staff interviews and video evidence showed that the resident’s urine had been dark brown to black and foul-smelling for weeks without appropriate assessment, documentation, or escalation. CNAs and LVNs reported that the urine appeared reddish, like iced tea, brown/blackish, and had a bad odor for approximately a month or a few weeks, and that they assumed it was normal after it remained that way; several nurses acknowledged they did not assess the catheter or urine every shift and did not consistently document or notify the physician about the worsening color. Video footage provided by the responsible party showed dark/black, opaque urine in the drainage bag on multiple nights, and hospital staff described the catheter on admission as draining purulent, very dark/black urine with foul odor, pus in the tubing, and mold on the catheter balloon and tip, suggesting it had not been changed for a long time. The facility’s own catheter policy required timely and appropriate assessments, ongoing monitoring for catheter-associated UTI, recognition and reporting of complications, and catheter and drainage bag changes based on clinical indications such as infection or obstruction. Despite these requirements and the resident’s known history of frequent UTIs and chronic catheter use, the facility did not assess, intervene, or change the catheter while the resident’s urine remained abnormal over an extended period, culminating in her transfer to the hospital where she was diagnosed with severe sepsis with septic shock likely from a UTI.
Removal Plan
- Performed a 100% audit (DON, ADON, Wound Care Nurse) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMR documentation accuracy, and catheter change dates.
- Replaced any urinary catheter immediately (by a licensed nurse) for residents with abnormal findings; notified physician immediately, implemented new orders promptly, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change on the importance of documenting all care provided (including catheter changes), with progressive discipline up to termination for further infractions.
- Completed an in-service for all licensed nurses and CNAs on catheter care/maintenance, UTI prevention, change-in-condition notification, documentation requirements, and when to notify the physician; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR, documentation, and initiated interventions during clinical meetings; addressed issues immediately with the licensed nurse and/or IDT, resident/RP, and physician as necessary; adopted as standard IDT review process for residents with catheters.
- Implemented DON/designee verification of catheter orders and documentation of catheter care and assessments; adopted as standard IDT review process for residents with catheters.
- Conducted visual checks by DON/designee to ensure catheter care is maintained and without abnormalities until 100% compliance is achieved; communicated potential issues to the IDT, resident/RP, and physician.
- Implemented a questionnaire process to validate effectiveness of the urinary catheter care process with licensed nurses, CNAs, and nurse managers; provided immediate re-education if staff could not answer appropriately.
- Ran a physician orders report to check and verify accuracy of any new catheter orders; immediately corrected issues; adopted as standard IDT review process for residents with catheters.
- Clarified and corrected incomplete/incorrect/conflicting catheter orders/documentation immediately when identified by DON/designee; adopted as standard IDT review process for residents with catheters.
- Conducted an impromptu QAPI meeting with the Medical Director to obtain approval of the action plan.
- Reported findings to the QI process and QA committee monthly (Administrator and DON/designee) and addressed any concerns/recommendations immediately.
Failure to Notify Physician of Worsening Hematuria and Catheter-Related Changes
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a physician when a resident experienced a significant change in condition related to an indwelling urinary catheter. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an ostomy, a feeding tube, and severe cognitive impairment. Her care plan identified her as dependent for all ADLs, at risk for anemia-related complications, and at risk for UTIs due to the presence of a catheter, with specific interventions directing staff to monitor, document, and report abnormal urine characteristics and signs and symptoms of UTI to the physician. Physician orders directed that the Foley catheter be changed PRN for signs and symptoms of infection, obstruction, or compromise of the closed system. Progress notes showed that on one date an LVN documented blood-tinged urine draining from the Foley catheter, low blood pressure, and that the physician was notified, resulting in orders for a urinalysis and IV fluids. A subsequent NP note documented dark orange/red urine, a contaminated UA with mixed microbial growth, the resident’s refusal of IV fluids, and plans for repeat labs. However, from that point through several days later, there was no documentation in the electronic health record of urine color, characteristics, or other changes in condition, and the last documented catheter change had occurred weeks earlier. Despite multiple staff observing that the urine had become dark brown to black, foul-smelling, and remained that way for weeks, there was no evidence that the physician or NP was notified of this worsening change in urine appearance. Video footage provided by the family showed CNAs draining a catheter bag on multiple nights, with the urine in the drainage bag and container appearing dark/black and opaque. Hospital staff later described the catheter from the facility as having mold on the balloon, strings of pus on the tip, purulent urine, and a very dark, almost black appearance with a strong odor, and hospital records documented septic shock likely from a UTI with the indwelling catheter draining purulent urine. Facility staff interviews revealed that CNAs and LVNs had noticed the urine as dark, brown, or black and malodorous for weeks, and some believed it had become “normal” for the resident or assumed prior notification had been sufficient. Several nurses acknowledged they did not consistently assess or document urine characteristics, did not follow up on the worsening urine color, and did not notify the physician again despite recognizing that such changes could indicate infection or kidney issues. The ADON, DON, NP, and Administrator all stated that the dark or black urine color seen in the videos was not normal for the resident and that they would have expected immediate notification and follow-up, but this did not occur until the resident became lethargic and confused with low blood pressure and low oxygen saturation, at which point the physician was notified and the resident was sent to the hospital and diagnosed with severe sepsis and septic shock likely due to UTI.
Removal Plan
- Performed a 100% audit (by DON, ADON, Wound Care Nurse, RN) of residents with catheters to verify catheter placement/securement, urine characteristics, signs/symptoms of UTI, EMAR documentation accuracy, and catheter change documentation.
- Replaced urinary catheters by a licensed nurse for any resident with abnormal catheter-related findings; notified the physician, obtained and implemented new orders, notified the resident’s responsible party, and increased monitoring every shift.
- Provided a 1:1 in-service to the LVN who failed to document catheter change and notify the physician regarding change in condition/urine appearance/consistency, emphasizing reporting to physician/NP and responsible party and documenting in the EMAR; advised further infractions may result in discipline up to termination.
- Provided in-service training for all licensed nurses on catheter care/maintenance, UTI prevention, change-in-condition notification to physician/NP and responsible party, and documentation requirements; staff were not permitted to return to resident care until in-services were completed.
- Implemented DON/designee review of resident changes in condition via SBAR and documentation, and initiated interventions during clinical meetings; addressed issues immediately with physician/NP notification and review with licensed nurses and/or IDT; adopted as standard IDT review process for residents with catheters.
- Conducted a QAPI meeting with the Medical Director to notify of potential noncompliance and obtain approval of the action plan.
- Reported findings to the QI process and QA committee, with immediate follow-up on any concerns or recommendations.
Failure to Provide Ordered Daily Wound Care Resulting in Infected Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered daily wound care to a resident with multiple pressure ulcers, resulting in an infected left hip wound. The resident, a 75-year-old man, was admitted with severe protein-calorie malnutrition, metabolic encephalopathy, peripheral vascular disease, and existing pressure ulcers, including sacral and right heel ulcers and osteomyelitis of the right ankle and foot. On readmission from the hospital, he had multiple pressure injuries: unstageable pressure ulcers on both hips, a stage 4 ulcer on the left posterior shoulder, a stage 3 coccyx ulcer, an unstageable ulcer on the left medial lateral foot, and a DTPI on the left 5th toe. Physician orders dated 2/11/26 required that each wound be treated every day shift with normal saline, pat dry, and application of Santyl, calcium alginate, and border foam dressings, and that the DTPI on the 5th toe be treated with betadine and iota every day shift. Despite these orders, the treatment administration record (TAR) showed wound care documented only on 2/22/26, with all wound care documentation left blank for 2/23/26, 2/24/26, and 2/25/26. Nursing staff interviews revealed inconsistent and uncorroborated accounts of whether wound care was actually performed on those days. RN A stated she last dressed the wounds on 2/23/26 and could not explain the lack of documentation; no other staff could confirm that wound care occurred that day. LVN E claimed she performed wound care on 2/24/26 but admitted she did not document it in the TAR, stating she could not find the resident’s name and did not seek assistance from other nurses. CNA and nurse interviews about wound care performed on 2/26/26 indicated that the dressings still bore RN A’s initials from the prior treatment and appeared unchanged for 2–3 days, with staff noting a bad odor and drainage from the left hip wound. On 2/27/26, observations and interviews documented that the resident’s room had a strong foul odor, which staff attributed to his wounds. During wound care that day, the Wound Care Doctor found the right hip wound to be very dark with mostly eschar and moderate drainage, and described the left hip wound as unstageable, very smelly, and appearing infected, with purulent and serosanguinous drainage and a yellow-tinged exudate that suggested depth. The left hip wound measured larger than previously documented and was diagnosed as infected. The Wound Care Doctor stated that if the resident had received wound care on the missed days, it could have helped prevent the decline of the left hip wound, although he could not say the infection was unavoidable due to the resident’s comorbidities and poor nutrition. Hospice staff also stated that while the resident’s wounds were considered unavoidable due to his condition, having wounds that were not being treated constituted neglect and that infections were avoidable. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to provide necessary pressure ulcer treatment and services as ordered.
Removal Plan
- Resident #1 was immediately assessed by the Wound Care Doctor and diagnosed with an infected unstageable pressure ulcer to the left hip.
- Physician orders were obtained for Clindamycin 450 mg three times daily for 14 days to treat the wound infection.
- Wound care resumed immediately per physician order (daily day shift treatment).
- Wound cultures were ordered and obtained.
- The DON initiated direct oversight of wound care completion and documentation.
- The facility reviewed the census and identified all residents with wounds.
- A 100% audit was completed of all wound treatment orders and TAR documentation.
- Head-to-toe skin assessments were completed for all current residents.
- Any identified documentation gaps were immediately corrected and treatments were provided.
- All licensed nurses were re-educated on the wound care policy, including treatment frequency, dressing type, and documentation requirements.
- Staff education included expectations for notifying the physician of any changes in wound condition.
- A daily wound care assignment sheet was implemented to ensure accountability.
- The DON or designee will perform daily spot checks of wound treatments.
- A daily audit of all wound treatments will be conducted for 14 days.
- Weekly audits will be conducted thereafter for 30 days.
- Audit results will be reviewed in the QAPI meeting.
- Staff failing to follow wound care procedures will receive immediate counseling and retraining.
- The facility will verify that all residents are receiving wound care as ordered, all licensed nurses have completed re-education, and monitoring systems are in place and functioning to ensure ongoing compliance.
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.
Failure to Integrate Heel Off-Loading and Repositioning into Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes that reflected a resident’s identified needs for pressure injury prevention. The resident was an older female with multiple complex medical conditions, including malnutrition, COPD/asthma, toxic encephalopathy, alcohol dependence, muscle wasting and atrophy of the lower leg, cognitive communication deficit, and muscle weakness. A quarterly MDS showed severe cognitive impairment with a BIMS score of 6, total dependence for transfers and mobility, and complete bowel and bladder incontinence. The resident either refused or was unable to perform basic mobility tasks such as sit-to-lying, lying-to-sitting, sit-to-stand, transfers, and walking, placing her at high risk for pressure injuries. The resident’s care plan, initiated for pressure ulcer risk, identified a focus of potential for development of a pressure ulcer with a goal that the resident would be free of preventable breakdown. Interventions listed included frequent checks for wetness and soiling, incontinence care every two hours as needed, scheduled bathing, and weekly skin checks with reporting of new skin conditions to the physician. However, the care plan did not include interventions for off-loading the heels or repositioning every two hours, despite the resident’s immobility and incontinence. The Braden Scale completed at admission rated the resident as low risk with a score of 16, and the facility’s documentation showed no skilled observation notes for skin assessments from early January through late February, and subsequent notes described the skin as intact with no notable changes. Hospital documentation in the facility’s EHR from before admission showed a prevention plan that specifically ordered heel off-loading using heel protector boots or pillows lengthwise. Later, a wound care physician’s evaluation documented that the resident developed unstageable deep tissue injuries (DTIs) on both heels, and a subsequent evaluation showed an unstageable DTI on the right heel and a Stage 4 pressure wound on the left heel. Interviews indicated that the family representative had not observed heel boots or pillows under the resident’s legs until after bandages were applied, and the NP reported that the resident had been admitted without pressure ulcers or DTIs, later developed heel blisters, and that orders for off-loading and heel boots were written. The DON and ADON acknowledged that repositioning was not reflected on the TAR/MAR, that heel riser boots had not yet been received, and that the care plan lacked interventions for off-loading heels and repositioning. These documented omissions and inconsistencies in care planning and implementation led to the identified deficiency under F656 for failure to develop and implement a comprehensive person-centered care plan.
Removal Plan
- DON/ADON conducted an audit of all current residents to determine which residents are at risk for pressure injuries (limited mobility, dependence on staff for repositioning, malnutrition, existing wounds, or recent decline).
- DON/ADON conducted an audit of residents identified as high-risk for skin breakdown (Braden scale score below 10) and reviewed residents with current wounds and significant change of condition to validate that comprehensive care plans addressed all issues with appropriate interventions and were updated as needed.
- For any resident identified with missing, incomplete, or outdated care plan interventions, the care plan was reviewed and revised immediately by the MDS Coordinator and DON.
- MDS nurse completed care plan updates for identified residents.
- DON/ADON re-educated licensed nurses, MDS staff, and interdisciplinary team members on requirements for comprehensive person-centered care planning, timely care plan revision after new wounds/condition changes, measurable objectives and individualized interventions, and communication of updated interventions to direct care staff via Kardex/POC system and documentation of care plan review/implementation.
- Implemented expectation that care plans are revised as soon as an issue is identified by the ADON responsible for wound care, with DON validating care plan revisions during morning meeting.
- Required that staff who did not attend the education will not work until education is completed; Administrator to track attendance and posttest completion.
- Established ongoing monitoring/audits by DON/ADON/MDS Coordinator for residents with new wounds, current pressure injuries, significant changes in condition, and identified skin risk factors to verify care plans are revised timely and interventions are individualized and implemented.
- Set audit schedule through QAPI as indicated.
- For any negative audit findings, correct immediately through care plan revision, staff re-education, and follow-up review.
- Bring audit results to the QAPI Committee for review, trend analysis, and additional corrective action as needed.
- Notified the Medical Director of the Immediate Jeopardy and discussed/obtained approval of the plan of removal.
Significant Insulin Reconciliation Error and Failure to Access Glucagon for Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration and emergency hypoglycemia treatment. The resident, an older male with Type II diabetes mellitus and multiple comorbidities including COPD, chronic kidney disease, atherosclerotic heart disease, atrial fibrillation, gout, and dysphagia, was originally admitted and later discharged following a hypoglycemic episode with a blood glucose level of 35. Upon readmission from the hospital, the discharge instructions included an order for Insulin Glargine 12 units once daily and regular insulin on a sliding scale before meals, with explicit instructions to stop Insulin degludec (Tresiba) 40 units once daily. The facility’s March 2026 MAR showed that these new insulin orders were not transcribed and that the prior order for Tresiba 40 units at bedtime was continued. On the readmission date, LVN A completed admission assessments but did not review the hospital discharge medication list, stating that two nurses typically split admission tasks and that the charge nurse handled the medication review. LVN B, the charge nurse on the readmission date, reported that he completed the medication reconciliation but acknowledged he failed to accurately reconcile the medications and transcribe the correct insulin orders, resulting in continuation of Tresiba instead of initiating Insulin Glargine and regular insulin per hospital instructions. The attending physician later stated he had instructed the facility to follow hospital orders and expected nurses to accurately review discharge instructions and call with accurate information when verifying orders. On the night of the incorrect insulin administration, RN C, who was aware the resident had been readmitted but relied on the prior shift’s reconciliation, followed the existing physician orders and administered 40 units of Tresiba at bedtime after a blood glucose reading of 135. At approximately 5:10 a.m. the following morning, RN C obtained a blood glucose reading of 35. The resident was alert, able to sit upright, and had no difficulty swallowing. RN C administered sugar dissolved in peach juice and water while awaiting EMS. RN C reported being unable to locate the facility emergency kit containing glucagon injection or gel at that time. The DON later confirmed that glucagon gel and an injection were present in the emergency kit in the medication room but required 45 minutes of searching to locate it. The facility’s own policies on medication reconciliation and medication errors defined the need for accurate reconciliation of pre- and post-discharge medications and identified wrong-drug administration as a medication error, which was not followed in this case.
Removal Plan
- Notified the Medical Director of the Immediate Jeopardy.
- Completed a chart audit of all residents with diabetes mellitus to ensure orders were in place for glucagon injection or gel PRN for low blood sugar and signs of hypoglycemia.
- Implemented a Glucagon Audit Sheet to be completed daily by the charge nurse to ensure glucagon is available in the emergency kit.
- Established daily monitoring of the Glucagon Audit Sheet by the DON/ADON during the clinical meeting and by the weekend supervisor/designee on weekends.
- Completed an audit to confirm emergency glucagon orders were in place for all residents with diabetes mellitus.
- Located glucagon medication in the emergency kit in the medication room and re-labeled it with a large red label to allow it to be easily located.
- Implemented a policy requiring two nurses to review medication reconciliation for all new admissions and readmissions.
- Conducted an in-service for DON/ADON regarding the diabetes protocol and medication reconciliation on all admissions.
- Conducted an in-service for all full-time and part-time nurses on accurate medication reconciliation for new admissions/readmissions, the location of the emergency kit glucagon, and hypoglycemia/diabetes protocols.
- Established that DON/ADON will educate all new nursing staff on these trainings before they are allowed to work.
- Conducted an in-service for the weekend supervisor on reviewing medication reconciliation for all new admissions/readmissions and the location of the emergency kit glucagon.
- Implemented monitoring that the DON or designee will review each new admission physician order for accurate transcription at the daily clinical meeting.
- Implemented monitoring that the weekend supervisor or designee will monitor physician orders on weekends.
- Implemented weekly monitoring by the Regional Clinical Nurse during Quality Improvement reviews to ensure the plan of removal education remains in place.
- Implemented oversight by the Administrator to ensure IDT members review physician orders for all new admissions/readmissions at the clinical meeting and review effectiveness at the monthly QAPI meeting.
- Completed a QAPI meeting and implemented a Performance Improvement Plan in conjunction with the Plan of Removal.
Failure to Assess and Notify After Witnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice, the resident’s care plan, and the resident’s choices following a witnessed fall. An elderly male resident with severe cognitive impairment (BIMS score 00), Alzheimer’s dementia, non‑Alzheimer’s dementia, HTN, DM, CKD stage 2, and a history of wandering and fall risk was observed roaming in and out of other residents’ rooms on the memory unit. On the morning in question, an LVN reported that the resident became angry when redirected from another resident’s room, attempted to swing at the nurse, lost his balance, and fell, striking his face/head and torso against a hallway rail. The LVN observed an abrasion to the resident’s right temple/cheek area and applied a bandage. Despite this witnessed fall with head impact and visible injury, the LVN did not complete an immediate, comprehensive post‑fall assessment as required by facility policy and nursing standards. The electronic health record for that day contained no documentation of vital signs, head‑to‑toe assessment, neurological checks, fall assessment, post‑fall monitoring, pain assessment, or any change in condition related to the fall. The LVN later stated he had performed these assessments but acknowledged he did not document them and did not call for assistance from other clinical staff. He also did not notify the physician, DON, ADON, or weekend supervisor of the fall and injury, although he claimed to have verbally informed an unidentified weekend supervisor who, according to the weekend supervisor interviewed, was never notified. The resident’s family was not informed of the fall or injury at the time it occurred. When the responsible party and another family member visited later that day, they observed a bloody bandage on the resident’s cheek and noted increased confusion and changes in alertness. During a three‑way call with the LVN, the nurse disclosed that the resident had fallen earlier that morning, admitted he had not notified the family because he was unaware he needed to do so, and reassured them that the resident was “fine” and being monitored. Concerned about the resident’s condition, the family requested to take him to the hospital and signed him out on leave. At the hospital, the resident was found to have sustained right 6th and 7th lateral rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s records showed that required post‑fall assessments and notifications were not completed at the time of the incident, and key facility staff, including the DON, ADON, weekend supervisor, and NP, confirmed they were not promptly notified of the fall or the resident’s head injury.
Removal Plan
- Notify the Medical Director.
- Complete an ad hoc QA review to address notification protocols for family and physician for incidents/accidents and change of condition, including proper assessments and documentation.
- DON/designee to educate licensed nurses on proper assessments and documentation for incidents/accidents, including any resident change of condition.
- DON/designee to educate licensed nurses to notify the DON and Administrator of all incidents/accidents and change of condition that require hospital transfer.
- DON/designee to assess all residents with falls in the past 30 days to ensure proper notifications and assessments are in place.
- MDS/designee to update care plans for all residents with falls in the last 30 days.
- Educate all licensed nurses on incident/accident protocols, including notification of the DON, Administrator, physician and family, and resident assessment and documentation prior to working their next assigned shift.
- DON/designee to monitor residents with falls daily to ensure notifications, assessments, and documentation are in place.
- Administrator to review with the DON weekly to ensure continued compliance.
- DON to bring results of all audits to the QAPI committee for review and continued recommendations/compliance.
- Include this protocol in new-hire orientation by DON/designee.
Failure to Notify Physician and Family After Resident Fall With Significant Injuries
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician and notify the resident’s representative after an accident that resulted in injury and had the potential to require physician intervention. The affected resident was an elderly male with severe cognitive impairment, Spanish-speaking only, with diagnoses including anemia, HTN, DM, CKD stage 2, Alzheimer’s dementia, and non-Alzheimer’s dementia. His admission MDS showed a BIMS score of 00, indicating he was unable to complete the interview, and he required supervision or partial assistance with mobility, transfers, toileting, and ADLs. He had a history of wandering and behaviors such as restlessness, disorganized speech, abusive or resistant behavior, and was care planned as at risk for falls and wandering, with interventions including frequent visual checks and redirection. On the morning in question, the resident was reported by the primary nurse (LVN-L) to have been roaming in and out of other residents’ rooms and requiring frequent redirection. According to LVN-L’s later interview, at approximately 7:30 AM the resident became angry when redirected, attempted to swing at the nurse, lost his balance, and fell hard against a hallway handrail, striking his face/head and torso. LVN-L stated he observed an abrasion to the right temple/cheek area, helped the resident off the floor, cleaned and bandaged the area, and claimed he completed vitals, skin, fall, and neuro assessments with regular observations, and that the resident was ambulatory, not in pain, and functioning at baseline. However, the resident’s electronic health record for that date contained no clinical documentation of vital signs, fall assessment, post-fall monitoring, neurological assessments, pain assessments, or any change-in-condition assessments related to the fall. There were also no completed post-fall assessments by LVN-L in the record. Later that day, the resident’s family visited and, at about 5:00 PM, observed a bloody bandage on his face and noted a change in his mental status. During a conference call with LVN-L, the family learned for the first time that the resident had fallen and hit his head on the rail earlier that morning. The family questioned why they had not been notified and expressed concern about increased confusion. LVN-L acknowledged to the family and to the surveyor that he had not notified the responsible party, the physician, the DON, the ADON, or the weekend supervisor about the fall and injury, stating he was not aware he needed to notify the family and that he was busy with 60 residents and ongoing behaviors. He told the family the resident was fine and allowed them to sign the resident out and transport him to the hospital on leave rather than arranging emergency transport. Hospital records later showed the resident had right 6th and 7th rib fractures, a right adrenal hematoma, and a grade 3 liver laceration. The facility’s medical provider (NP-A) reported he was not notified of the fall details until two days later and stated he expected immediate notification when a resident falls with a head injury. Interviews with the Administrator, DON, ADON, weekend supervisor, other nurses, and CNAs consistently described that facility protocol required immediate assessment, documentation, and notification of the physician, responsible party, and nursing leadership after a fall or change in condition, and that this did not occur in this case.
Removal Plan
- Medical Director notified
- Ad hoc QA completed to address notification protocols of family and physician for incident/accidents and change of condition
- DON/designee to educate licensed nurses on proper notification of physician and family for incident/accidents to include any resident change of condition
- DON/designee to educate licensed nurses to notify DON and administrator of all incident/accidents and change of condition that require hospital transfer
- DON/designee performed assessments on all residents with falls in the past 30 days to ensure proper notifications and assessments in place
- MDS/designee updated care plans for all residents with falls in the last 30 days
- All licensed nurses will be educated on incident/accident protocols, to include notification of DON, Administrator, physician and family and resident assessment prior to working their next assigned shift
- DON and/or designee will monitor residents with falls daily to ensure notifications were appropriately made to physician and family
- Administrator to review with the DON weekly to ensure continued compliance
- Results of all audits will be brought to the QAPI committee by DON to review for continued recommendations and compliance
- Protocol will be covered on new-hire orientation by DON/designee
Elopement of Cognitively Impaired Resident Due to Inadequate Supervision and Security Screening
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent accidents when a cognitively impaired resident was able to leave the building unnoticed during the night and was later found on a public street. The resident was an older female admitted for rehabilitation after a cerebral infarction (stroke) and had a Brief Interview for Mental Status (BIMS) score of 7/15, indicating severe cognitive impairment. Her care plan identified an ADL self-care performance deficit related to weakness and deconditioning from a recent hospital stay, with interventions focused on encouraging participation in care, use of the call bell, explanation of procedures, and PT/OT evaluation and treatment. The care plan did not identify or address elopement risk or specific supervision needs related to her cognitive status. On the night of the incident, nursing documentation shows that at approximately 11:00 p.m. the resident was observed in bed sleeping and vital signs were taken without changes. Around 1:00–1:15 a.m., the RN making rounds discovered the resident was no longer in her bed, checked her bathroom and adjacent rooms, and did not find her. Security was alerted, and the RN searched the stairwell and pool area without locating the resident, then proceeded to the front of the building. A security guard reported that he had allowed a woman to exit the building around that time, believing she was homeless. Staff then searched outside and found the resident walking on a pedestrian walkway along the road to the right side of the building. She was returned to the facility, assessed with no injuries noted, and one-on-one supervision was initiated. Interviews and record reviews revealed multiple failures in supervision and identification that led to the elopement. The security guard stated he saw the resident in the swimming pool area, opened a locked gate for her when she could not open it, and escorted her out the front door without asking her name or any identifying questions, without checking for identification, and without notifying nursing staff. He reported assuming she was homeless based on her statement that she came through a back door used by homeless individuals and stated he did not see any identifying bracelets or clothing that would make him think she was a resident, although the family member reported the resident was wearing a fall-risk bracelet and a visible heart monitor. The facility had a pool area and dog park accessible from emergency exits and gates, and the resident was able to reach these areas and then the front of the building without being recognized or stopped by staff. The family member and speech therapist both described the resident as having significant cognitive and communication deficits, including difficulty understanding verbal instructions, needing repeated explanations and visual aids, and not consistently being oriented to person, place, or time, yet these deficits were not effectively incorporated into supervision practices that would have prevented her from leaving the facility unnoticed.
Removal Plan
- Instituted immediate monitoring of emergency exit doors leading outside to the pool and common areas by assigning a staff person at each door of egress; implemented a sign-in/sign-out sheet and prohibited resident/visitor/staff exit unless there is an emergency; ensured assigned staff are relieved for breaks/lunches with documentation on an assigned form.
- Implemented staff exterior walking rounds with documentation, including hourly rounds in the dog park and pool areas; verified dog park gate and pool gate are secured with staff initials.
- Implemented walkie-talkie protocol: charge nurses check out walkie talkies at the beginning of each shift and return them at the end to enhance communication with security.
- Re-educated staff on emergency exit and fire door usage: staff must not use these doors unless there is an emergency and must investigate each time an alarm sounds.
- Re-educated staff on elopement/missing resident procedures: alert staff by calling a Code Yellow, complete skills check quiz for each employee, and ensure elopement binders are located on the 1st and 2nd floor nurses' stations and at the front desk.
- Provided in-service on abuse and neglect (definitions, types, reporting) and identified the abuse coordinator.
- Provided instant in-service on unfamiliar person protocol to remind staff of obligations to identify all persons on the property.
- Completed elopement risk assessments on all residents in the facility.
- Conducted impromptu QAPI meetings addressing resident elopement, binder use, behavior monitoring, swimming pool concerns, and staff assignment at fire door/egress monitoring.
- Began facility-wide education on emergency exit usage and alarm investigation for all departments; ensured staff not in-serviced would be in-serviced prior to their next shift with documentation.
- Completed facility-wide education on resident elopement/missing resident search procedure, proper notification, resident assessments, and resident monitoring; ensured staff not reeducated would be reeducated before their next shift; began elopement skills testing with documentation.
- Began facility-wide education on abuse and neglect (definitions, abuse coordinator, types, importance of timely notification); ensured staff not reeducated would be reeducated before their next shift; implemented abuse/neglect skills testing once per shift.
- Re-educated security/concierge staff on initial contact and verification of a wandering resident: ask identifying questions, check for identifying markers, call nurses’ stations to verify, and refer to the elopement binder; required retraining prior to returning to duty with documentation.
- Implemented additional communication protocol between nursing and front desk/security using walkie talkies: devices located/charged at concierge desk; at least one security associate and one direct care associate on each floor carry walkie talkies; one issued per floor with sign-out and return at end of shift; education completed prior to next shift with documentation.
- Educated night shift staff on security protocol, unfamiliar persons protocol, and abuse and neglect.
- Provided immediate re-education to all security and concierge staff on safety monitoring protocols: hourly walking rounds in pool and dog park areas, continuous monitoring of pool area via security cameras with feed visible at all times, prompt reporting of adverse findings to leadership, and accurate/timely documentation; documented on an in-service sheet.
- Re-educated the Healthcare Administrator on the facility abuse policy and elopement policy.
- Regional Director of Clinical Services educated the Executive Director and Healthcare Administrator on missing resident policy and swimming pool/spa policy.
- Provided ongoing oversight by the Executive Director and Healthcare Administrator to ensure adherence to protocols, with prompt corrective action and additional training for deviations.
- Placed a staff member at the emergency exit door between the dog park and pool area to redirect anyone attempting to exit unless there is an active emergency; maintained coverage until the gate could be reassessed and an appropriate locking mechanism installed.
- Scheduled a meeting with an approved technology company with the Administrator, Director of Maintenance, and Executive Director to assess and implement an appropriate locking mechanism for the gate between the dog park and pool area.
- Required security to complete hourly walking rounds of the pool and dog park areas; document and report any adverse findings to the Director of Resident Services, Executive Director, and Healthcare Administrator.
- Reviewed the pool area policy and reaffirmed that access is restricted to Independent Living residents and skilled care residents are not allowed access.
- Conducted monitoring observations and interviews across all shifts to verify in-service training completion and staff competencies/understanding, including reenactment drills and knowledge checks.
Failure to Honor Resident’s Documented DNR Status During Code Blue Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Out-of-Hospital Do Not Resuscitate (OOH DNR) order and documented DNR status when the resident was found unresponsive and staff initiated resuscitation. The resident was an older female with diagnoses including depression, anxiety disorder, ALS, and a tracheostomy, and had a BIMS score of 15, indicating she was cognitively intact. Her care plan, physician orders, and an OOH DNR form signed by the physician and two witnesses all documented that her code status was DNR. Despite this, when she was found unresponsive in her room, staff proceeded with CPR and other resuscitative measures after determining she had no pulse and had stopped breathing. According to interviews and record review, an agency CNA discovered the resident unresponsive and notified an LVN, who assessed the resident and noted she was pale but breathing, with a weak pulse. Another LVN entered, performed a sternal rub and other stimuli without response, while the first LVN rechecked pulses at multiple sites and then reported finding no pulse and that the resident had stopped breathing. At that point, a Code Blue was called. Respiratory therapy staff removed the breathing circuit from the tracheostomy, suctioned the airway, and began manual ventilation with an ambu bag. Another LVN began chest compressions. During this period, staff questioned whether the resident was a DNR or full code, and there was hesitation because the LVN leading the response was unsure of the resident’s code status. Staff reported that the crash cart binder, which they relied on to verify code status, was not up to date and contained DNR information for residents who were no longer in the facility. The LVN in charge stated she attempted to verify the resident’s status by checking the crash cart binder and then the electronic medical record, but resuscitation had already been initiated and continued while this verification was pending. EMS arrived and continued compressions, and a pulse was recovered before the LVN informed EMS that the resident was actually a DNR based on the documentation she eventually located. The resident’s responsible party later confirmed that a DNR had been completed at the hospital and again at the facility, and stated that the resident did not want CPR, including having her ribs cracked, and that the facility did not abide by the resident’s wishes. The facility did not have a specific policy for Out-of-Hospital DNRs, only a general resident rights policy stating that residents have the right to refuse treatment.
Removal Plan
- Provided in-service training to staff on resident rights, including: Timely Emergency Services & Professional Standards for CPR; How to Identify the Resident Code Status; and Abuse & Neglect.
- Required all new hires to complete the in-service trainings on resident rights, code status, and CPR-related standards.
- Implemented a process for night shift nurses to print the daily resident census, highlight residents with DNR status, and place the dated census sheet in each crash cart binder along with a copy of each resident’s DNR.
- Implemented a process for morning-shift ADONs to check crash cart binders for accuracy and needed DNR code status updates.
- Implemented DON review of resident code status and crash cart binder accuracy.
- Implemented use of a Standard of Care (SOC) spreadsheet that includes a DNR column and records the date of any code status change; tracked by the corporate nurse.
- Implemented audits of printed reports for new admissions to verify code status and ensure crash cart binders are updated accordingly.
- Implemented a process for the Social Worker to deliver newly executed DNR documentation to the DON for updating the electronic medical record and adding the DNR to the crash cart binder and SOC tracking.
- Implemented a DON audit of resident charts for DNR documentation.
- Implemented corporate nurse audits of SOCs.
Failure to Recognize and Report Resident’s Deteriorating Condition and Hypotension
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices when there was a clear change in condition. The resident was an adult male with Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a physician. On the day in question, a medication aide documented hypotensive blood pressure readings of 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., but there was no corresponding change-in-condition assessment completed that day, and the low readings were not effectively communicated to the licensed nurses responsible for his care. Throughout that day and night, multiple staff observed and described significant deviations from the resident’s usual baseline without ensuring appropriate nursing assessment and provider notification. A CNA working the day shift reported that the resident, who normally liked to play on his computer, slept most of the day and did not eat breakfast or lunch except for one cup of vanilla pudding; he stated he told the floor nurse but could not recall who it was or what action was taken. Another CNA on the night shift stated the resident was “out of it,” barely spoke, slept most of the shift despite usually staying up late, had heavy breathing, and only nodded his head with eyes closed in response to questions; she reported communicating these concerns to the night nurse and checking on him several times. The medication aide on the 2:00 p.m. – 10:00 p.m. shift acknowledged that the resident’s blood pressure was low and that he held the resident’s blood pressure medication, but he could not clearly identify which nurse he informed or what the nurse’s response was. Licensed nurses on both shifts reported that they were not made aware of the resident’s low blood pressure readings or his refusal of meals. The day-shift LVN stated she received no notifications from CNAs or medication aides that the resident had low blood pressure or had not eaten, and she indicated she would have contacted the provider if she had known of a systolic reading of 86. The night-shift LVN stated she checked on the resident several times, received nods or brief verbal responses, and did not recognize a change in behavior; she also stated she was told by a CNA that the resident had not eaten breakfast or lunch but believed that CNA had already informed the day nurse. Neither LVN had knowledge of the documented hypotensive readings. The following morning, another LVN found the resident barely responsive, clammy, with an untouched breakfast tray, a blood pressure of 75/54, and unresponsiveness to a sternal rub, at which point EMS was called and the resident was sent to the hospital. Hospital staff and the primary medical doctor later described the resident as having been deteriorating for hours, with findings including blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and he required multiple rounds of CPR. The facility’s own policy titled “Change in Resident Condition” required that when there was a significant change in a resident’s physical, mental, or psychosocial status, the medical provider should be contacted. The DON stated that when the medication aide identified low blood pressure, he should have notified the nurse immediately, and that CNAs and medication aides were expected to provide verbal updates to nurses, who in turn were responsible for notifying the provider, completing documentation, and ensuring oversight. In this case, despite documented hypotension, decreased intake, increased sleepiness, and altered responsiveness over many hours, there was a breakdown in communication and follow-through: the low blood pressure readings were not effectively reported to the LVNs, no change-in-condition assessment was completed on the day of the abnormal readings, and the provider was not contacted about the resident’s change in condition until the following morning when he was found unresponsive and required emergency transfer. The primary medical doctor later stated that the resident was found unresponsive to a hard sternal rub with low blood pressure and vomit around his mouth, and that he appeared to have been deteriorating for hours. A hospital registered nurse reported that the resident was admitted due to unresponsiveness, required three rounds of CPR because his heart stopped, and imaging and cultures showed an infarct and blood infection. A hospital nurse practitioner stated that the resident was positive for a blood infection, septic shock, mucus in the lungs, hypoglycemia, and an acute stroke, and that his unresponsiveness was caused by multiple factors. The resident’s family member reported that his mind had been very sharp despite prior stroke-related mobility issues and expressed gratitude that the LVN who found him unresponsive returned to check on him, stating that this likely saved his life. These findings collectively demonstrate that staff did not act in accordance with the resident’s care plan and facility policy regarding timely recognition, assessment, and reporting of a significant change in condition.
Removal Plan
- Removed medication aide #1 from his assignment pending completion of in-service training on Medication Administration, Reporting of Abnormal Vital Signs to the charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action related to failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process, including: evaluation/assessment; documenting findings (vital signs and Change in Condition assessment/progress note); reporting changes to the medical provider; notifying the resident representative; documenting all actions in the EHR; reviewing medication aide vital sign forms for abnormalities with reassessment/interventions; reporting changes to the oncoming nurse during handoff.
- Required that no nursing staff work their next assigned shift until all required in-service training is completed.
- Educated all certified medication aides on medication administration (five rights) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process, including when to use it, completing it in the EHR and/or on paper, communicating it to the nurse, and turning the form in to the charge nurse for nurse follow-up.
- Required the nurse to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the Director of Nursing when a change in condition is identified and Stop and Watch is completed, including that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse’s station and specified secure storage locations for staff use.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for State surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication/orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all nursing staff on leave/PRN are in-serviced prior to working their shift and that administrative nursing staff provide in-service/education prior to staff working their next assigned shift.
- Implemented ongoing monitoring/verification using a Change in Condition audit tool with audits to ensure compliance.
- Implemented/maintained medication aide vital sign monitoring logs and required medication aides to handwrite vital signs on the designated form and submit to the charge nurse for review.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F684 and the plan of removal.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The deficiency involves the facility’s failure to consult with a resident’s physician when there was a significant change in the resident’s physical, mental, or psychosocial status. The resident was an adult male with multiple serious diagnoses, including Type 2 diabetes, cardiac implants and grafts, morbid obesity, hypertension, and a prior cerebral infarction, and was documented as full code. His care plan directed staff to monitor vital signs and report all changes in condition to a doctor. On one day, his blood pressure readings taken by a medication aide were 89/59 at 2:31 p.m. and 86/57 at 7:08 p.m., which were hypotensive. There was no documentation that a Change in Condition (CIC) assessment was completed that day, and no progress notes indicated that the physician had been notified of these low blood pressure readings or of any change in condition. Staff interviews and records showed that the resident’s condition had changed over the same period without appropriate escalation to a provider. CNAs reported that the resident, who was normally alert, communicative, and active on his computer, slept most of the day and night, was very sleepy, did not eat breakfast or lunch except for one cup of pudding, and had minimal verbal communication, sometimes only nodding his head with eyes closed and heavy breathing. A CNA stated he informed the floor nurse that the resident had not eaten and was very sleepy but could not recall the nurse’s name or what action was taken. A medication aide stated he held the resident’s blood pressure medication due to low blood pressure and told an unidentified nurse, but he could not say which nurse or what the nurse’s response was. The nurses who worked those shifts stated they were not informed of the low blood pressure readings or the resident’s poor intake and increased sleepiness. The following morning, an LVN entering the resident’s room found him drowsy, barely speaking, with an untouched breakfast tray, clammy to the touch, and with a low blood pressure of 75/54. The LVN documented that the resident was unresponsive to a sternal rub and was sent out due to an acute change in condition, hypotension, increased work of breathing, and unresponsiveness; EMS, the provider, the DON, and family were notified at that time. Subsequent hospital information obtained by surveyors indicated the resident was admitted to ICU for unresponsiveness, required multiple rounds of CPR after his heart stopped, and was diagnosed with a blood infection, septic shock, mucus in his lungs, and an acute stroke, with a blood sugar of 63. The resident’s primary medical doctor reported that when he saw the resident at the hospital, the resident had vomit around his mouth, appeared to have been deteriorating for hours, and had technically passed away twice but was resuscitated. The facility’s DON confirmed that per policy, providers should be informed of all significant changes, and that CNAs and medication aides were expected to report changes to nurses, who in turn were to notify the provider and document the change in condition, which did not occur in this case. An Immediate Jeopardy was identified related to this failure to notify the physician of the significant change in condition.
Removal Plan
- Removed medication aide #1 from assignment pending completion of in-service training on Medication Administration, reporting abnormal vital signs to charge nurse, Abuse/Neglect, and Residents Rights.
- Counseled medication aide #1 and issued a written performance action for failure to report low blood pressure readings to the charge nurse.
- Re-educated all licensed nurses on the expected change-in-condition process: evaluation/assessment, documentation (vital signs and Change in Condition assessment/progress note), reporting to the medical provider, notification of resident representative, and ensuring all steps are documented in the EHR.
- Required licensed nurses to review medication aide vital sign forms to identify abnormal vital signs, re-assess residents, implement interventions, notify the medical provider and resident representative, and document actions in the EHR.
- Required nurses to report identified/suspected changes in condition to the oncoming nurse during shift handoff to ensure continuity of reporting.
- Prohibited any nursing staff (full-time, part-time, PRN, or on leave) from working their next assigned shift until all required in-service training was completed.
- Educated all certified medication aides on medication administration (rights of medication administration) and the requirement to notify the charge nurse of any abnormal vital signs.
- Educated all team members on the Stop and Watch process for subtle changes in condition and expectations for use.
- Required Stop and Watch forms to be completed in the EHR and/or on paper, communicated to the nurse, and paper forms turned in to the charge nurse for nurse follow-up assessment and notifications.
- Required nurses to provide a copy of the Stop and Watch paper form to the Director of Nursing Services.
- Required all nursing team members to notify the DON when a change in condition is identified and Stop and Watch is completed, including confirmation that assessment and provider/representative notifications were made.
- Made blank Stop and Watch forms readily available at the nurse's station.
- Placed a copy of the Stop and Watch form in the Plan of Removal/Abatement binder for state surveyor review.
- Completed a 100% audit of all residents to identify any residents with a change in condition and ensured appropriate assessments, provider communication, orders, documentation, representative notification, and updates to the 24-hour communication report.
- Provided education to all nursing team members on Abuse/Neglect and Residents Rights.
- Ensured all PRN/on-leave nursing staff are in-serviced prior to working their next shift and that administrative nursing staff provide in-service/education prior to staff working.
- Ensured all residents receive appropriate care after a change in condition.
- Conducted an ad hoc meeting with the Administrator, DON, and Medical Director to address the immediacy issue related to F580 and the plan of removal to lift immediate jeopardy.
- Required certified medication aides to handwrite all vital signs on the designated vital sign form/log and turn it in to the charge nurse.
- Placed a copy of the medication aide vital sign form/log in the Abatement/Plan of Removal binder for state surveyor review.
- Ensured Stop and Watch forms were available in designated locations for staff access and use.
- Required DON notification by phone when a Stop and Watch form is completed and a change in condition is identified.
Single-Staff Hoyer Transfer and Delayed Assessment Lead to Severe Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfers and adequate supervision during a mechanical lift transfer for one resident, resulting in serious injuries. The resident was an elderly female with Alzheimer’s disease, dementia, prior stroke, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers. Her care plan and Kardex specified that she was non–weight bearing and required a Hoyer lift with two staff for all transfers. Earlier on the day in question, she had been seen by facility physicians and nursing staff, and had received a shower and Hoyer transfer with two staff, with no bruises, skin tears, edema, or leg injury documented or observed. On the evening and night shift, a CNA assigned to the resident’s hall was instructed to put the resident to bed. The CNA reported that she took a Hoyer lift she had used on another resident and transferred this resident from wheelchair to bed by herself, despite knowing that Hoyer transfers required two staff and that the resident was a two-person Hoyer transfer. She stated she did not ask for help and acknowledged she had been trained that Hoyer lifts required two staff, although she also claimed she had not been trained on the Hoyer at this facility and said she did not check the Kardex because she did not have access. Another CNA confirmed that all Hoyer transfers were supposed to be done with two staff and that the resident’s requirements were available in the Kardex. The facility’s written Safe Resident Handling/Transfers policy required two staff for mechanical lift transfers and mandated that transfers be performed according to the resident’s plan of care. After the single-staff Hoyer transfer, the CNA and another aide assisted with repositioning the resident in bed. During this time, skin tears and bruising on the resident’s arms were observed. The assisting CNA reported that the skin tears appeared bloody and asked what had happened; she was told by the primary CNA that the injuries were old and that the nurse was aware. The primary CNA stated she informed the nurse that the resident appeared in pain, but the nurse allegedly responded that the resident would be screaming if she were in pain. The CNA also reported noticing bruising on the resident’s left leg and said she told her supervisor and the nurse, and was told the leg was always like that or that it was edema and to elevate it. The nurse on duty acknowledged being notified around early morning that the resident’s leg appeared bruised or swollen but did not immediately assess the resident, instead instructing that the leg be elevated while she continued care for another resident. By the following morning, when the day-shift LVN assessed the resident at the request of the night nurse, extensive injuries were found. The assessment revealed bilateral bruising to both arms, multiple skin tears with missing top layers of skin and no flaps, a large bruise on the back, a scratch on the forehead, and swelling, discoloration, and obvious deformity of the left lower extremity. The resident grimaced and moaned with touch or movement. Hospital evaluation documented a forehead abrasion, severe hematoma and contusions of the upper extremities with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling. Police photographs showed purple and red bruising on both hands with fresh and dried blood on the sheets, and the left leg bruised, purple, inflamed, and turned in an abnormal direction. There were no documented falls or incidents that could explain these injuries, and staff interviews did not identify any reported event, leaving the single-staff Hoyer transfer and subsequent lack of timely assessment after reported changes in condition as the central actions and inactions leading to the deficiency. The facility’s internal investigation confirmed that there were no abnormal findings on the resident earlier that day, including during a shower and physician visits, and that no staff reported any fall or incident during the night. The CNA who performed the transfer admitted using the Hoyer lift alone for this dependent, non–weight-bearing resident, contrary to the care plan, Kardex, and facility policy. The night nurse acknowledged failing to assess the resident after being notified of a change in her leg’s condition. The day nurse, who had last seen the resident without injuries the prior evening, found extensive new bruising, skin tears, and leg deformity the next morning. The combination of a one-person mechanical lift transfer for a resident care-planned for two-person Hoyer use, failure to follow the safe transfer policy and plan of care, and failure to promptly assess and document a reported change in condition led to the identified deficiency in ensuring the environment was free from accident hazards and that residents received adequate supervision and assistance to prevent accidents.
Removal Plan
- Completed facility-wide skin assessments with no new or abnormal findings identified.
- Conducted environmental and safety rounds with no hazards or abnormal findings identified.
- Conducted resident safe surveys; residents reported they felt safe in the facility environment.
- Provided staff education on abuse, neglect, and exploitation policies.
- Completed mechanical lift competencies with nursing staff.
- Reviewed electronic records of residents; no issues identified with assessments.
- Held an AD HOC QAPI meeting with the interdisciplinary team and involved police notification, social work, and the Regional Nurse; implemented ongoing daily monitoring of residents.
- Implemented staff training and competency testing/demonstration covering abuse, neglect, reporting, documentation, transfers, resident assessment, and pain assessment.
- Conducted in-services for all direct care staff (in person and/or via phone); staff not present were not permitted to work their assignment until in-serviced; new hires to be in-serviced during orientation; agency staff to be in-serviced prior to working their floor assignment.
- Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, abuse coordinator identification, and immediate reporting of abuse/neglect with 100% staff trained.
- Completed nursing staff training and competencies for skin assessment and pain assessments with 100% nursing staff trained.
Failure to Assess Change in Condition and Perform Safe Hoyer Transfer Resulting in Severe Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely assessment and care in accordance with professional standards of practice and the resident’s care plan after a reported change in condition. The resident was an elderly female with Alzheimer’s disease, dementia, prior cerebral infarction, muscle weakness, severe cognitive impairment (BIMS-4), and total dependence for all ADLs and transfers, requiring a two-person Hoyer lift transfer at all times. Her care plan and Kardex both identified her as non–weight bearing and requiring Hoyer lift with two staff. On the afternoon of the day before the incident, documentation by an LVN indicated no edema or injuries, and a late-night note by another LVN documented edema but did not specify location, grade, or associated pain. During the night shift, a CNA transferred the resident from wheelchair to bed using a Hoyer lift alone, despite knowing the resident required a two-person Hoyer transfer and acknowledging awareness that Hoyer lifts required two staff. The CNA reported not being trained on the Hoyer lift at the facility and not checking the Kardex due to lack of access to the electronic system. After the transfer, while providing incontinence care, the CNA noticed bruising on the resident’s left leg and skin tears on her arms near the wrists. The CNA stated she informed a CNA supervisor, who allegedly said the leg had always been like that and did not check it, and that she also informed the night-shift LVN that the resident appeared to be in pain and asked the LVN to look at the leg. The LVN reportedly responded that the resident would be screaming if she was in pain and later, when shown the resident’s left foot with edema around 5:10–5:15 a.m., told the CNA to elevate the leg and then continued providing care to other residents without immediately assessing the resident. The LVN who had worked the prior day shift and returned for the morning shift stated that the resident had no bruises, edema, or skin tears when she left the previous evening. After receiving morning report, this LVN was asked by the night LVN to assess the resident at approximately 6:40 a.m. Upon pulling back the covers, she observed extensive new findings: discoloration and bruising to both arms and the right thigh, left lower extremity swelling and discoloration, multiple skin tears with missing top skin and no flaps, a knot on the right forearm, a scratch on the forehead, a large bruise on the back, fresh blood on the gown and blankets, and significant pain responses (grimacing, moaning, and frowning) when the resident was touched or moved. The resident was unable to articulate what had happened and denied falling or being harmed when questioned. Hospital evaluation documented a forehead abrasion, obvious deformity of the left lower extremity, severe hematoma of the right upper extremity, bilateral upper extremity contusions with avulsion injuries around both wrists, and displaced comminuted fractures of the distal shafts of the left tibia and fibula with soft tissue swelling, with concern for elder abuse noted. The facility’s investigation found no reported falls or incidents that could explain the injuries, confirmed that the night LVN had been notified of leg changes but did not promptly assess the resident, and classified the situation as an Immediate Jeopardy related to failure to assess and respond to a change in condition and to follow safe transfer requirements.
Removal Plan
- Suspended CNA A and LVN C immediately pending investigation
- Terminated LVN C for failure to assess and document a resident after being notified of a change in condition
- Completed facility-wide skin assessments with no new or abnormal findings
- Conducted environmental and safety rounds with no hazards or abnormal findings identified
- Conducted resident safe surveys with residents reporting they feel safe in the facility environment
- Provided staff education on abuse, neglect, and exploitation policies
- Completed mechanical lift (Hoyer) competencies with nursing staff
- Conducted targeted staff interviews with employees who had direct contact with the resident within the previous 72 hours regarding observed abnormalities and reporting
- Re-educated staff regarding the role of the Facility Abuse Coordinator, incident and accident reporting, documentation requirements, and charting expectations
- Reviewed electronic records of residents for assessment issues; no issues identified
- Held an AD HOC QAPI meeting with the interdisciplinary team to review the incident and identify system improvements
- Implemented staff training and competency testing/demonstration on abuse/neglect/reporting, documentation, transfers, resident assessment, and pain assessment
- Conducted in-services for all direct care staff; staff not present were not permitted to work their assignment until in-serviced
- In-serviced all new hires during facility orientation
- In-serviced all agency staff prior to working their floor assignment
- Completed in-service training on falls, documentation, Stop and Watch alert tool in PCC, and reporting abuse/neglect immediately to the Abuse Coordinator; 100% of staff trained
- Completed nursing staff training and competencies on skin assessments and pain assessments; 100% of nursing staff trained
- Conducted impromptu observations and skills/knowledge checks of Hoyer lift transfers and resident assessments
- Conducted daily reviews of resident records for assessments via daily 24-hour report review
- Monitored staff daily and conducted impromptu knowledge checks
- Reviewed 24-hour reports daily and reviewed resident charts for required charting
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident’s elopement from the building without staff knowledge. The resident was an elderly male with dementia, prior cerebral infarction, hemiplegia/hemiparesis, generalized muscle weakness, and atherosclerotic heart disease. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment. An Elopement Risk Assessment completed shortly after admission scored him at 16, identifying him as at high risk for elopement, but his care plan dated 03/02/26 did not include elopement risk as a focus with goals or interventions. Progress notes from admission through the date of the incident documented no prior elopement attempts or exit-seeking behaviors. On the night of the incident, the east exit door alarm sounded at approximately 01:00 a.m. The nurse on duty, RN A, reported that she immediately went to the door and looked but did not see any residents; she then conducted a head count and discovered that the resident was missing. The DON stated that RN A did not go outside the building to look for the resident when the door alarm sounded, and the administrator stated it was the nurse’s responsibility to go around the building at the time of the alarm. While the alarm had sounded and staff were searching, a CNA who worked on another floor encountered the resident outside around 12:30 a.m.; the CNA later stated in writing that he thought the man was homeless and did not recognize him as a resident because he worked on a different floor and had never seen him before. After the resident was identified as missing, staff initiated the facility’s elopement/missing resident protocol and searched the building and surrounding premises, and local law enforcement was notified. Within a short time, police contacted the facility to report that the resident had been found wandering off facility grounds and transported him to a hospital for evaluation. The administrator reported that the resident was found near a hospital or a crossing bridge near the hospital, at least as far as the main road and not near the facility, estimating the distance as a 5–10 minute walk or longer for this resident. Hospital evaluation and subsequent skin assessment on return documented no injuries or acute issues. The DON later acknowledged that the resident’s high elopement risk score had been known, that the care plan should have reflected monitoring for elopement/exit-seeking behaviors, and that staff had not notified her when the resident’s initial elopement assessment score exceeded the facility’s high-risk threshold.
Removal Plan
- All staff received training on abuse and neglect as well as training on elopement response with emphasis on the need to check outside the building in response to door alarms.
- All residents were reassessed for elopement risks.
- An AD Hoc QAPI meeting was conducted to review the elopement.
- Door locks and alarms were checked and are checked daily.
- Door alarm monitoring and missing resident/elopement monitoring are completed daily.
- Door alarm codes continue to be changed monthly.
- Elopement drills are conducted three times per week.
- The DON monitors all residents' elopement scores daily by generating and reviewing a daily report for changes and scores over 10.
Trusted by long-term care providers and associations.
Find your facility
Search by name to see its inspection history, citations and penalties — and how to prepare for the next survey.
