Citations in Texas
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Texas.
Statistics for Texas (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Texas
Surveyors found that food preparation equipment, including muffin pans, baking sheets, skillets, and steam table pans, had significant debris buildup and flaking anti-stick coating. The Dietary Manager acknowledged that these conditions could contribute to foodborne illness, and facility policies require all food-contact surfaces to be clean and sanitized after each use.
A gas stove in the kitchen was found to have a non-functioning front left burner and left side oven, both of which required manual ignition with a lighter due to a failed pilot light. The dietary manager confirmed that the stove should ignite automatically and no policy on equipment maintenance was provided when requested.
Two residents did not receive medications as ordered by their physicians: one received an incorrect dose of vitamin D, and another was given Clonidine outside of prescribed blood pressure parameters. Medication aides acknowledged the errors, which were attributed to oversight and not following physician orders as documented in the medication administration records.
Two residents received medications without proper adherence to physician orders: one was given a blood thinner without an appropriate diagnosis documented, and another received multiple doses of an antihypertensive medication outside of the prescribed blood pressure parameters. Staff interviews confirmed that medications were administered without following the required indications and parameters.
A resident with hypertension received Clonidine outside of physician-ordered blood pressure parameters on multiple occasions. Medication aides administered the drug when the resident's systolic BP was below the specified threshold, contrary to the written order. Staff interviews and documentation confirmed the medication was given in error, and facility policy required adherence to physician instructions.
A medication aide left a blister pack of allopurinol tablets and a souffle cup with assorted pills unattended on top of a locked medication cart while stepping away multiple times, including to wash hands and retrieve supplies. The medications were out of the aide's line of sight, and at one point, a resident in a wheelchair was observed near the unattended cart. Both the DON and Administrator confirmed that facility policy requires medications to be secured and in view at all times, and the aide acknowledged the lapse in following these procedures.
Three residents continued to receive psychotropic medications at higher doses despite pharmacy and physician recommendations for gradual dose reductions. In each case, the required dose reductions were either not implemented or not documented, and staff interviews revealed a lack of oversight and awareness regarding these medication changes.
Several residents reported receiving cold meals, and surveyors confirmed that food items served during a lunch meal were not at appropriate temperatures. The Dietary Manager acknowledged ongoing complaints and identified delays in meal distribution as a contributing factor, with no effective resolution implemented despite reporting the issue to facility leadership.
Staff failed to hold and serve hot foods, including regular and pureed corn and pureed chicken strips, at the required temperature of 140°F or above. Food was served at temperatures between 130°F and 132°F, contrary to facility policy and professional standards, and staff did not reheat the food before serving.
Three residents had personal refrigerators filled with undated food items and no visible thermometers, with no clear staff responsibility for monitoring temperatures or cleanliness. Staff interviews revealed confusion about who was responsible for these tasks, and temperature logs showed potentially inaccurate readings despite the absence of thermometers. The facility's policy placed responsibility on residents and families, but lack of enforcement led to improper food storage and monitoring.
Unsanitary Food Equipment and Surfaces in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to maintain sanitary conditions in the kitchen, specifically regarding the cleanliness and condition of food preparation equipment. During inspections, multiple muffin pans, baking sheets, and skillets were found with dark brown or black debris baked onto both the inside and outside surfaces. Additionally, one skillet was noted to have its anti-stick coating flaking off, and several steam table pans had brown debris buildup on the top corners. These items were stacked together and used in food preparation and service. Interviews with the Dietary Manager confirmed that pans should be clean and free of debris buildup, and that such buildup could contribute to foodborne illness. Review of the facility's Infection Control Policy and the FDA Food Code indicated that food-contact surfaces and equipment should be kept free of encrusted grease deposits and other soil accumulations, and that dirty equipment should not come into contact with food. The facility's failure to adhere to these standards was directly observed during meal preparation and kitchen inspections.
Failure to Maintain Kitchen Stove in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove in the kitchen. During an observation, it was found that the front left burner and the left side oven of the stove would not ignite when the knobs were turned. The dietary manager (DM) reported that the pilot light was out and used a multipurpose lighter to manually ignite both the burner and the oven. The DM acknowledged that the stove should ignite without the use of a lighter and expressed concern that lighting the stove in this manner could be hazardous. No facility policy regarding equipment maintenance and operation was provided when requested by the surveyor. Record review referenced the FDA Food Code 2022, which requires equipment to be maintained in good repair and proper adjustment.
Failure to Administer Medications as Ordered by Physicians
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications as ordered by physicians for two residents. For one resident with a history of protein-calorie malnutrition, hypertension, and chronic ischemic heart disease, the medication aide administered only 1,000 units of vitamin D instead of the physician-ordered 2,000 units. The medication aide acknowledged the error, stating it was a mistake and that she believed she was following the order at the time. The resident's care plan included interventions to give medications as ordered, but the full prescribed dose was not administered. For another resident with hypertension and hypertension urgency, staff failed to follow physician-prescribed parameters for administering Clonidine, a medication used to lower blood pressure. The physician's order specified that Clonidine should be given only when the systolic blood pressure (SBP) was greater than 160. However, the medication was administered on multiple occasions when the resident's SBP was below this threshold. Medication aides involved in these incidents admitted to not holding the medication as required and attributed the errors to oversight and not reading the order carefully. Interviews with staff, including medication aides and the Director of Nursing, confirmed that medications were not always administered according to physician orders and established parameters. The facility's policy required medications to be administered in accordance with written physician orders, but this was not consistently followed, resulting in medication errors for both residents.
Failure to Ensure Drug Regimens Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary medications, as evidenced by two separate incidents involving two residents. One resident, a male with a history of heart valve replacement, pacemaker, and congestive heart failure (CHF), was administered Eliquis, a blood thinner, without an appropriate diagnosis documented in the facility records. The hospital records indicated Eliquis was given for a pacemaker, while the facility’s physician orders listed CHF as the indication. During interviews, staff were unable to confirm the correct diagnosis for the medication, and the Director of Nursing (DON) clarified that Eliquis should be indicated for atrial fibrillation or pacemaker, not CHF. Another resident, a female with diagnoses of hypertension urgency and essential hypertension, received Clonidine, an antihypertensive medication, outside of the prescribed parameters. The physician’s order specified that Clonidine should be administered only if the systolic blood pressure (SBP) was greater than 160. However, medication administration records showed that the medication was given on multiple occasions when the resident’s SBP was below this threshold. Medication aides involved acknowledged during interviews that the medication should have been held according to the parameters and attributed the errors to oversight and not reading the order carefully. Facility policy required medications to be administered in accordance with written physician orders. Despite this, the staff failed to follow the specified parameters for medication administration and did not ensure that medications were given only with appropriate indications. These actions resulted in the administration of unnecessary medications and doses, as documented in the residents’ records and confirmed by staff interviews.
Failure to Follow Physician-Ordered Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not adhering to physician-ordered parameters for administering Clonidine, a blood pressure medication. Specifically, the medication was given nine times in January 2026 when the resident's systolic blood pressure was below the ordered threshold of 160, contrary to the physician's instructions. Documentation on the medication administration record (MAR) confirmed that the medication was administered outside the prescribed parameters, and interviews with medication aides and nursing staff acknowledged the oversight and failure to follow the order as written. The resident involved was an older female with diagnoses of hypertension urgency and essential hypertension, who was cognitively intact according to her most recent assessment. Her care plan and physician orders clearly specified the conditions under which Clonidine should be administered. Despite this, medication aides administered the drug when the resident's blood pressure readings did not meet the required criteria. Staff interviews revealed that the medication should have been withheld in these instances, and the facility's policy required medications to be given in accordance with physician orders.
Unattended Medications Left on Medication Cart
Penalty
Summary
A medication aide (MA) failed to properly secure medications during a medication pass on Hall 600. The aide left a blister pack containing 10 white oval pills and a souffle cup with 4 assorted pills on top of a locked medication cart while stepping away to wash hands and later to retrieve additional medication supplies. During these times, the medications were unattended and out of the aide's line of sight, with no staff or residents immediately present at first, but later a resident in a wheelchair was observed near the unattended cart. Multiple staff members also walked past the unattended cart during this period. The aide acknowledged during interviews that the medications should not have been left unattended on top of the cart and confirmed that she had been trained on proper medication storage and cart security. She explained that she left the medications out because she had a question about them and did not want to forget, but admitted this was not in accordance with her training. The medications included allopurinol tablets intended for a single resident, and the aide recognized the potential for someone else to take the medication while it was left unsecured. Facility policy, as reviewed, requires that medication carts be locked when not in use and that medications remain in the clear view and reach of the person administering them. Both the DON and the Administrator confirmed in interviews that staff are expected to maintain visual contact with medication carts at all times and never leave medications unattended on top of the cart. The incident was observed and confirmed by surveyors, and the facility's policies were found to be consistent with accepted professional principles for medication security.
Failure to Implement and Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications underwent required gradual dose reductions (GDRs) and behavioral interventions, unless clinically contraindicated, as part of efforts to discontinue these drugs. For three residents reviewed, there were lapses in following through with pharmacy recommendations and physician-approved dose reductions. Specifically, one resident with dementia and major depressive disorder continued to receive a higher dose of citalopram despite a physician-approved reduction, with the dose only being adjusted after surveyor intervention. Medication administration records confirmed the resident received the higher dose for over a month after the reduction was approved. Another resident with paranoid schizophrenia and depression was supposed to have their duloxetine dose reduced from 60 mg to 40 mg following agreement from a psychiatric nurse practitioner, but records showed the reduction was never implemented. The medication administration records indicated the resident continued to receive the higher dose for several months after the recommendation and approval for reduction. A third resident with bipolar disorder and schizophrenia was prescribed Invega Sustenna and olanzapine. Although pharmacy recommendations for GDRs were made, there was no documentation that these reductions were attempted or that behavioral interventions were implemented. Interviews with facility staff, including the ADON, DON, and Administrator, revealed a lack of awareness and oversight regarding the pharmacy recommendations and the status of GDRs. The facility's own policy required documentation of GDR attempts and outcomes, but such documentation was missing for these residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for residents during a reviewed lunch meal. Multiple residents reported receiving cold food, and direct observation by surveyors and the Dietary Manager confirmed that the chicken fried chicken was lukewarm, while the mashed potatoes and corn were cold. The Dietary Manager acknowledged that the food items were not at the appropriate temperature and stated that she had received similar complaints from residents in the past. She also indicated that the food was hot when it left the kitchen, but delays in meal distribution by staff resulted in residents receiving cold meals. Interviews revealed that the issue of cold food had been reported to the Administrator, DON, and previous Administrators, but no resolution had been implemented. The Dietary Manager suggested the use of closed carts to keep meals warmer, but this suggestion was not acted upon. The Administrator confirmed that the nursing department was responsible for ensuring timely delivery of meals to residents and acknowledged that cold food would not be appetizing. Review of the facility's policy indicated that food should be served at the proper temperature and in an attractive manner, which was not achieved during the observed meal service.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, it was found that regular texture corn, pureed corn, and pureed chicken strips were being held at temperatures below the required 140°F on the steam table. Specifically, the foods were measured at 130°F and 132°F. Staff interviews confirmed that food should be held at or above 140°F, and if not, it should be reheated to at least 165°F before serving. However, the staff member responsible for serving the trays did not reheat the food, stating she was focused on starting meal service and did not consider reheating at the time. The Dietary Manager and Administrator both acknowledged that food should be held at the proper temperature, with the Dietary Manager preferring 165°F and confirming that food not at the correct temperature should be reheated. The facility's policy also requires that all hot foods be cooked and held for service at 140°F or above, and any food not meeting this standard should be reheated to 165°F. Despite these policies and expectations, the food was served at temperatures below the required threshold, and the Dietary Manager stated she had not previously observed incorrect food temperatures.
Failure to Monitor and Maintain Safe Storage of Resident Food in Personal Refrigerators
Penalty
Summary
The facility failed to implement and enforce a policy regarding the use and storage of foods brought to residents by family and other visitors, specifically in relation to the monitoring and maintenance of personal refrigerators in resident rooms. Observations revealed that three residents had personal refrigerators that were packed with undated food items and lacked visible thermometers. Interviews with these residents indicated that they were either unsure of who was responsible for checking the refrigerator temperatures or believed that no one was regularly monitoring them. Review of temperature logs showed consistent, possibly inaccurate temperature recordings, despite the absence of thermometers in the refrigerators during the survey period. Staff interviews demonstrated confusion and lack of clarity regarding responsibility for monitoring and maintaining the cleanliness and temperature of residents' personal refrigerators. Various staff members, including LVNs, maintenance, housekeeping, and CNAs, provided conflicting statements about who was responsible for these tasks. The housekeeping supervisor mentioned keeping a temperature log and attempting to clean the refrigerators but noted that residents sometimes refused access. The administrator and DON both acknowledged the importance of monitoring refrigerator temperatures but also indicated uncertainty about which staff were assigned to this duty. A review of the facility's Food and Nutrition Services policy revealed that the responsibility for monitoring the interior temperature of personal refrigerators was assigned to residents and/or their family members, with a requirement to keep food at 40 degrees Fahrenheit or less and to discard perishable foods within seven days. However, the lack of enforcement and oversight of this policy led to the deficiency, as evidenced by the absence of thermometers, undated food items, and inconsistent temperature monitoring in the residents' personal refrigerators.
Some of the Latest Corrective Actions taken by Facilities in Texas
- Established dual-licensed-nurse verification of admission and readmission medication reconciliation to ensure EMR orders match discharge summaries (K - F0760 - TX)
- Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification for every new resident entry (K - F0760 - TX)
- Required immediate physician notification, clarification, and documentation when medication discrepancies are identified (K - F0760 - TX)
- Implemented DON/designee review of all new admissions and readmissions by the next business day to verify reconciliation accuracy (K - F0760 - TX)
- Initiated weekly audits of all new admissions and readmissions for medication-reconciliation compliance, with results reviewed by the Administrator and incorporated into QAPI (K - F0760 - TX)
- Provided targeted re-education to licensed nurses on medication reconciliation, physician order verification, escalation steps, and documentation, with competency validation (K - F0760 - TX)
- Mandated nursing management notification of the Regional Nurse for any significant medication error requiring physician intervention or hospitalization (K - F0760 - TX)
Significant Medication Errors Due to Admission Process Failures
Penalty
Summary
A facility failed to ensure residents were free from significant medication errors, resulting in a resident receiving multiple medications that were not prescribed to him. Upon admission, the admitting nurse entered medications into the resident's medical record without verifying them against an accurate and current medication list. The facility's physician subsequently signed off on these orders without reviewing or verifying the resident's diagnoses with the nurse. The records provided by the transferring facility included another resident's medication administration record (MAR) mixed in with the correct resident's records, leading to the erroneous transcription and administration of medications. The resident, who had a history of Parkinson's disease, vascular dementia, hypothyroidism, bradycardia, hyperlipidemia, anemia, and a cardiac pacemaker, was administered medications including Metformin, Insulin Glargine, Farxiga, Lasix, and Insulin Lispro, none of which were prescribed for him. The MAR and care plan did not accurately reflect the resident's diagnoses or medication needs. The error was discovered after the resident was found unresponsive, with abnormal vital signs and a sudden change in neurological status. The family was notified, and upon review, it was found that the resident had been given medications intended for another patient due to the mixed records. The resident was transferred to the hospital, where he was diagnosed with acute renal failure, aspiration pneumonia, and sepsis. The facility's internal investigation confirmed that the error stemmed from the admission process, where medication reconciliation was not properly performed, and the physician relied on nursing staff for accurate order entry. The incident was determined to be an Immediate Jeopardy situation due to the failure to provide necessary goods and services to avoid physical harm.
Removal Plan
- The resident was transferred to the hospital and no longer resides in the facility.
- The Director of Nursing (DON) or designee conducted a facility-wide review of all residents admitted or readmitted to ensure medication orders were accurately reconciled with hospital discharge instructions and physician orders, including any transfers from other facilities.
- Nursing supervisors verified MAR accuracy, medication availability, and physician clarification as needed. Any discrepancies identified were corrected.
- The Administrator reviewed the audit findings and confirmed that no additional residents were at risk.
- The staff member who input the orders was terminated by the DON.
- All staff will be in-serviced by the DON/designee on abuse, neglect, and misappropriation. Staff members who are not present will be in-serviced prior to working their next shift and before providing resident care. Completion will be verified and documented.
- Revised the admission and readmission medication reconciliation process to require dual verification confirming that admit orders/discharge summary matches the orders entered in the EMR by the admitting nurse and another licensed nurse.
- The DON/designee established a requirement for immediate physician notification, clarification, and documentation when discrepancies are identified.
- Updated the admission checklist to include MD verification, dual nurse verification, and DON/designee verification to be completed for every admission and readmission.
- The DON/Designee will verify that the admission checklist is completed for all admissions.
- Required DON or designee review of all new admissions and readmissions by next business day.
- The Director of Nursing (DON) or designee will provide re-education to all licensed nursing staff on proper medication reconciliation, verification of physician orders prior to medication administration, escalation procedures, and documentation requirements. Education will be provided by the DON/designee through in-service training, with staff competency validated through verbal review. Staff members who are not present will be in-serviced prior to working their next shift and before providing resident care. Completion will be verified and documented.
- Nursing management will notify the Regional Nurse of any significant medication error requiring physician intervention or hospitalization.
- The Regional nurse notified the administrator to in-service nurse management regarding notification of the regional nurse of any significant medication error requiring physician intervention or hospitalization.
- The Director of Nursing (DON) or designee will conduct weekly audits of all new admissions and readmissions to ensure continued compliance with medication reconciliation requirements.
- Audit results will be reviewed by the Administrator and incorporated into the facility's QAPI program.
- Any identified noncompliance will result in immediate corrective action and re-education.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision and Intervention
Penalty
Summary
The facility failed to protect multiple residents from abuse, specifically physical aggression perpetrated by another resident with a history of severe cognitive impairment and behavioral disturbances. Several incidents occurred in which this resident physically assaulted peers, resulting in injuries and hospital evaluation for at least one victim. The aggressive resident had a documented history of Alzheimer's disease, depression, bipolar disorder, anxiety, and mood disorder, with a severely impaired cognition score. Despite being placed on 1:1 supervision due to repeated aggressive episodes, the resident continued to initiate unprovoked physical aggression toward others, including hitting, pushing, and punching fellow residents. The affected residents, all with varying degrees of cognitive impairment and complex medical histories, were subjected to physical aggression on multiple occasions. One resident was hit in the chest and fell, requiring hospital evaluation; another was punched in the face; a third was pushed to the ground; and a fourth was struck on the arm. Care plans for these residents documented the incidents and included interventions such as removal from the aggressor and monitoring for injuries. However, these measures did not prevent further occurrences of abuse, and staff interviews revealed ongoing concerns about the safety of both residents and staff due to the aggressor's unpredictable and escalating behavior. Staff and leadership interviews indicated that attempts to secure psychiatric intervention or alternative placement for the aggressive resident were unsuccessful, as hospitals and other facilities declined admission, and legal barriers prevented emergency detention. Staff reported feeling unsafe and unable to manage the resident's physical aggression, citing the resident's size and strength. The facility's abuse prevention policy emphasized the importance of resident safety, but the repeated incidents and lack of effective intervention resulted in the identification of Immediate Jeopardy by surveyors.
Removal Plan
- Ensure Resident #11 is placed on continuous 2:1 supervision at arm's length.
- Implement physical separation at arm's length between Resident #11 and all other residents at all times, accomplished by in-services to all staff.
- Place Resident #11 in a controlled, low-stimulation environment.
- Search the memory care common area and Resident #11's room to ensure objects that could be used to cause harm are removed from the resident's environment.
- Implement a two-staff approach for all care interactions involving Resident #11.
- Request and complete a psychiatric evaluation for Resident #11, with medication changes and additional diagnosis as a result.
- Review and adjust Resident #11's medication regimen and PRN parameters as clinically indicated.
- Review Resident #11's clinical status to assess for potential medical contributors to aggressive behavior, including pain assessment, vital signs, infection screening, bowel and bladder status, and medication profile.
- Revise the process for managing residents with aggressive behaviors, including early identification of triggers, defined escalation thresholds, and clear staff response expectations.
- Revise Resident #11's behavioral care plan by the interdisciplinary team to include identified triggers, early warning signs, de-escalation techniques, and clear direction for escalation.
- Educate DON and ADON regarding dementia-related aggressive behaviors, resident to resident abuse prevention, and de-escalation strategies, validated by quiz.
- Conduct education for staff on all shifts regarding dementia-related aggressive behaviors, resident-to-resident abuse prevention, and de-escalation strategies; staff, including PRN and Agency, will be unable to work until education is completed and validated by quizzes with a minimum score of 100%.
- Reinforce the Abuse Prevention Policy with specific focus on resident-to-resident aggression.
- Reinforce pathways of resources for staff for psychiatric consultation and alternative placement consideration and place in a binder at the nurses' station for staff accessibility.
- Conduct a house-wide assessment to identify residents at risk for harm, and implement protective interventions for all residents in the memory care unit.
- Provide immediate oversight of supervision levels and resident safety related to aggressive behaviors.
- Provide real time supervision during each shift to ensure protective interventions and separation measures remain in place; any escalation in aggressive behaviors results in immediate re-assessment and modification of interventions.
- Maintain active presence in oversight to ensure continued resident safety and adherence to interventions implemented to remove the jeopardy.
- Monitor resident-to-resident aggression through the QAPI program with trend analysis; review findings by the QAPI Committee and implement corrective actions as needed.
- Conduct ongoing audits to ensure compliance with supervision, care planning, and staff response protocols.
Failure to Supervise Cognitively Impaired Resident with Vehicle Access
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for a resident with Alzheimer's disease and moderately impaired cognition. The resident, who had a history of forgetfulness and required assistance with activities of daily living, was able to leave the facility multiple times without staff awareness or proper sign-out procedures. On several occasions, the resident left the premises in a personal vehicle, including one incident where he traveled to another city and another where he was found lost and returned by police. Despite these incidents, the resident's care plan did not initially include interventions addressing his access to a vehicle or his ability to drive. The facility's records showed that the resident's cognitive impairment and diagnosis of Alzheimer's were known, and staff were aware that he required supervision and cues for safety. However, after the resident left the facility and drove significant distances without staff knowledge, there were no immediate updates to his care plan to address the risk associated with his access to a vehicle. Interviews with staff and family confirmed that the resident was able to leave the facility unsupervised, and staff were not consistently verifying sign-out and return procedures. The resident's responsible party and staff expressed concerns about his ability to drive safely due to his cognitive deficits. The facility's policy required assessment and care planning for residents at risk of elopement or unsafe wandering, but these measures were not effectively implemented for this resident. Staff interviews revealed gaps in communication and understanding of protocols related to resident supervision and sign-out procedures. The lack of timely interventions and supervision allowed the resident to repeatedly leave the facility and operate a vehicle, despite clear risks associated with his medical condition and cognitive status.
Removal Plan
- Resident #1 received a head-to-toe assessment.
- Resident #1 was placed on 1:1 monitoring.
- The physician was notified and lab orders were obtained with no abnormalities noted.
- The care plan was updated with updated interventions of 1:1 monitoring, documenting exit seeking behaviors, and laboratory studies were completed.
- The vehicle belonging to Resident #1 which was on the premises was removed by resident's Relative Z and moved to her premises.
- Resident #1 has not driven a vehicle.
- The employee monitoring the reception desk was suspended and returned to work.
- Staff member was provided with 1:1 education on following proper out on pass process.
- Nursing administration conducted a facility wide audit of all current residents to determine if any residents were operating personal vehicles that were on the facility's premises.
- The facility completed an audit of all residents wandering evaluations.
- No new residents found at risk for wandering/elopement.
- The center developed and implemented a process to ensure safe and proper leaves of absence for residents: the center developed and implemented a Front Door Safety & Sign-Out Procedure.
- Staff members who assist with front desk reception duties were educated on the new process of Front Door Safety & Sign-Out Procedure to include competency check off.
- The facility initiated 100% reeducation on Elopement Protocols and the supervision of residents and ANE.
- The facility initiated 100% reeducation with the Charge Nurses on the process of Front Door Safety & Sign-Out Procedure.
- The training of direct care staff was completed in person or via telephone.
- Those that were not scheduled completed reeducation prior to accepting assignment for the next scheduled work.
- Verification of 100% of direct care staff education was verified by the Director of Nursing/ designee.
- Employee roster was utilized to validate completion.
Failure to Provide Required Two-Person Assistance During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a resident, a 93-year-old woman with a history of left femur fracture, peripheral vascular disease, and congestive heart failure, was not provided with the required level of assistance during a transfer from the toilet to her wheelchair. The resident's care plan and clinical assessments specified that she required a two-person assist and the use of a mechanical lift for transfers. On the date of the incident, only one CNA assisted the resident off the toilet, despite the care plan requirements. The resident's knee gave out during the transfer, causing her to fall and hit her knee on the toilet paper dispenser. She complained of pain, and subsequent x-rays revealed a broken femur, necessitating hospitalization and surgery. Interviews and record reviews revealed that the facility had ongoing staffing shortages, which led to frequent instances where only one staff member performed transfers that required two people. Multiple staff members, including CNAs and the ADON, acknowledged that one-person transfers for residents requiring two-person assistance were common due to inadequate staffing. Video evidence provided by the resident's representative also showed several instances where the resident was transferred by one staff member, both with and without a mechanical lift, in violation of facility policy and the resident's care plan. Further investigation indicated that some staff were unaware of how to access the resident's transfer requirements in the electronic Kardex, and communication lapses contributed to the failure to provide adequate assistance. The facility's own policies required two staff members for mechanical lift transfers and for residents assessed as needing two-person assistance. Despite these requirements, staff routinely performed one-person transfers, and the incident in question was directly linked to these practices. The deficiency was identified as Immediate Jeopardy due to the risk and actual harm caused to the resident.
Removal Plan
- Assess all residents requiring 2 person assist during transfer for any injuries.
- Provide 1:1 in-service to the CNA involved on Abuse and Neglect Policy, Mechanical Lifts Transfer, and use of the Electronic Medical Record for ADL Care Plan.
- Provide CNA retention checks, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements, and require return demonstration from CNA with all transfers with rehab director.
- Provide 1:1 in-service to the administrator, DON, and ADONs by the Regional Compliance Nurse and ADO on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, and determine competency by post test.
- Assess and determine staffing levels daily in accordance with the census and facility assessment, offer extra shift bonuses to staff as needed, provide sign on bonuses to attract new employees, contact company sister facilities for staffing assistance as needed, and build out the schedule at least 1 week in advance.
- Provide employee retention checks to Administrator and DON, including written in-service cheat sheets for quick reference, obtain signature and verbal acknowledgements.
- In-service all certified and licensed staff on Abuse and Neglect Policy, Mechanical Lift Transfers, and use of the Electronic Medical Record for ADL Care Plan, require all staff not present for the in-services to complete them before working, in-service all new hires during orientation, require staff to sign the in-service sheet, in-service all agency staff before scheduled shift, provide a posttest to confirm understanding, and require return demonstration for mechanical transfer check-off.
- Notify the Medical Director of the immediate jeopardy citation.
- Conduct ADHOC QAPI meeting with the IDT Team and the Medical Director to review the immediate jeopardy citation and plan of removal.
Failure to Prevent Resident Elopement Due to Unmonitored Exit and Non-Functioning Door Alarm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, a history of strokes, and impaired safety awareness eloped from the facility. The resident was able to exit through a door in Unit 3 vicinity hall 100, which was not properly monitored or secured during an EMS response for another resident's medical emergency. The door's 15-second delay alarm system was not functioning correctly, and staff were unaware of the malfunction. The resident was last seen in her room by staff and was later found missing during routine rounds. The facility's records indicated that the resident was considered low risk for elopement, and there was no prior evidence of exit-seeking behavior, but she had a history of confusion and required redirection when wandering into previous rooms. Staff interviews revealed that during the time of the emergency involving another resident, the exit door used by EMS was not monitored, and staff attention was diverted. Multiple staff members, including the DON, LVNs, and CNAs, stated they were not aware that the exit door alarm was not working. Additionally, it was observed that residents with high cognitive scores had access to the keypad code for the exit doors, and there was no list of which residents knew the codes. The facility's logbook for door checks was incomplete, and not all exit doors were being checked as required by policy. The resident was missing for several days, during which time she was exposed to cold weather and missed her medications, before being found by law enforcement on a bus and taken to the hospital. The facility failed to follow its own elopement prevention and response policies, which required all exit doors to have functioning alarms and to be checked each shift, as well as monitoring of doors during EMS entry and exit. The responsible party (guardian) was not notified immediately of the resident's elopement, and there was a delay in communication. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's elopement and exposure to potential harm.
Removal Plan
- Resident #8 was readmitted to a room across from the nurse's station for better monitoring and placed on one-to-one supervision to assure safety and monitor for elopement tendencies.
- Implement a check procedure with nursing to document Resident #8's presence.
- Activities and meal attendance for Resident #8 will be completed with an escort.
- All exit doors were checked by Maintenance to confirm alarms were operational and documented.
- Any EMS arrival requires a dedicated staff member posted at the door to maintain supervision during the entire EMS presence in the building.
- A full resident headcount was completed by the DON to ensure no other residents were missing or unaccounted for.
- All on-duty staff were re-educated on elopement prevention policy, door-monitoring requirements during emergencies, and that exit codes will not be shared with residents or visitors.
- Random competency quizzes will be completed.
- Exit door audits will be completed.
- Review of elopement risk assessments for all residents, including Resident #8.
- Full staff retraining on elopement procedures, supervision, and emergency response for all active personnel, with PRN or leave staff retrained prior to return.
- Maintenance audit of all door alarms will be completed.
- Administrator/DON will audit 100% of EMS entry/exit logs, door monitoring logs, and elopement assessments.
- Mock elopement drills will be completed.
- All audits and drill results will be reviewed in Standards of Care meetings, with immediate corrective action for any deviations.
Failure to Follow Care Plan Results in Resident Injury Due to Inadequate Assistance
Penalty
Summary
A certified nursing assistant (CNA) failed to follow the care plan for a male resident with multiple diagnoses, including cerebrovascular accident, non-Alzheimer's dementia, Parkinson's disease, dysphasia, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff, requiring two-person assistance for bed mobility, transfers, and activities of daily living. Despite this, the CNA attempted to provide in-bed care alone, turned the resident onto his side, and the resident subsequently rolled off the bed, sustaining a laceration to the left forehead that required sutures and hospital evaluation. The CNA admitted to not checking the Kardex to confirm the required level of assistance and stated she had always provided care to this resident alone, unaware of the two-person assist requirement. The care plan and Kardex both indicated the need for two-person assistance, but this was overlooked. The incident was witnessed by another staff member, and the resident was found on the floor with active bleeding. The nurse on duty confirmed that the CNA did not request help and that the care plan clearly required two-person assistance for bed mobility and transfers. Interviews with facility leadership revealed inconsistent understanding of the resident's care requirements, with the DON initially believing the resident was a one-person assist and only learning of the two-person requirement after the incident. The administrator did not conduct an independent investigation and relied on the DON's report, attributing the incident to a possible typo in the care plan and oversight by the CNA. The failure to follow the care plan and ensure staff were aware of and adhered to residents' assistance needs resulted in the resident's injury and constituted neglect as defined by facility policy.
Removal Plan
- CNA A in-serviced one-on-one by DON on resident positioning, bed mobility, using draw sheet, and getting assistance when needed.
- CNA A terminated and has not worked since.
- All staff in-serviced on Abuse/Neglect/Exploitation, Incidents/Accidents, and how to safely care for dependent residents, completed by ADON with Compliance Nurse oversight.
- DON/Administrator in-serviced on Abuse, Neglect, Incidents, and Investigating, including immediate suspension of employee accused of abuse/neglect, completed by Compliance Nurse.
- 100% audit completed to review plan of care, Kardex, and care profile on residents who are dependent assistance, completed by DON/ADON or designee with Compliance Nurse oversight.
- Care guides reviewed for compliance and accuracy, completed by DON/ADON or designee with Compliance Nurse oversight.
- Nursing staff in-serviced on guidance for accessing Kardex, care plans, and how to safely care for residents with positioning and incontinent care, completed by DON/ADON/designee.
- Weekend supervisor trained to monitor incidents/accidents on weekends and immediately report any issues identified to Administrator/DON by DON.
- All incidents reviewed and no other instances of abuse or neglect noted from the audit, completed by DON/Admin.
- Incident with Resident #1 self-reported via email by DON.
- Investigation initiated; facility self-reported the incident.
- All Abuse/Neglect allegations will be reported and investigated per policy; DON and Administrator will ensure investigations are completed timely.
- Administrator oversight provided by Regional President of Operations.
- No employees will be allowed to return to work until they have been in-serviced on the Abuse/Neglect policy and how to safely care for residents.
- Nurses will be responsible for ensuring compliance; DON/ADON/Admin will monitor.
- Incidents/Accidents and Complaints will be reviewed daily by DON or designee, weekend supervisor, and reported to Administrator immediately for investigation.
- Clinical review team (Admin, DON, ADON, MDS, Director of Operation) will discuss all incidents and accidents.
- Admin/DON will monitor to ensure compliance.
Failure to Maintain Secured Unit Doors and Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
The facility failed to ensure that the resident environment remained as free from accident hazards as possible and did not provide adequate supervision and assistance devices to prevent accidents for one resident identified as an elopement risk. The secured unit's 800 hall door alarm and lock were not functioning properly, which allowed a resident with a history of elopement and multiple diagnoses, including vascular dementia, schizophrenia, and cerebral palsy, to exit the facility unsupervised. The resident was found outside in the parking lot by staff, and it was noted that the alarm on the door was not heard by staff at the time of the incident. Record reviews indicated that the resident had previously been identified as a high elopement risk, with documented incidents of leaving the facility and a care plan in place that included interventions such as 1:1 monitoring and frequent checks. Despite these interventions, staff interviews revealed inconsistent practices regarding door checks and alarm functionality. Several staff members, including CNAs and nurses, reported that they did not know why the secured unit door was unlocked or why the alarm was not functioning at the time of the incident. Maintenance and nursing staff also reported finding the door unlocked and the alarm not working on other occasions, raising concerns about the reliability of the security measures in place. Observations by surveyors further confirmed that the secured unit doors were found unlocked and unmonitored during their visit, with no staff present in the area and multiple residents standing near the unsecured doors. Staff interviews indicated a lack of awareness and communication regarding the status of the doors and alarms, as well as uncertainty about procedures when maintenance was being performed. Documentation logs indicated that the doors and alarms were supposed to be checked daily, but these checks did not prevent the deficiency from occurring.
Removal Plan
- Resident was returned to unit by CNA and assessed for injury by nurse working shift.
- Resident was placed on monitoring every 15 minutes until risk resolved.
- Maintenance supervisor checked all doors on the secured unit for alarms and proper functioning.
- The nurse completed head count to ensure all residents were safe on the unit.
- In-services started with secured unit staff and other departments to ensure unit remains secure, and residents remain safe.
- Administrator or designee will in service all employees that work or will work on secured unit prior to starting their shift so they are made aware of changes.
- Inservice consists of nursing making walking rounds to check the alarms doors for proper functioning at the beginning and end of each shift.
- Secured unit staff is to always have 2 staff members.
- CNA must report to nurse when taking break and nurse must inform other nurse on duty when she is on break and inform CNA staff when nurse is taking break and who to contact in case any issues occur.
- Administrator in-serviced environmental supervisor - laundry staff should be making rounds on secured unit and collecting soiled linen. This allows secured unit staff to remain on secured unit to provide supervision and care to residents.
- Laundry Staff were in serviced by environmental supervisor.
- In-services completed by Administrator with maintenance supervisor that she must remain on secured unit any time that maintenance is being done on secured unit and inform staff when maintenance is being done.
- Check the doors to make sure they remain locked.
- Administrator started in services with secured unit staff so they are aware the secured unit must always have 2 employees on the secured unit for resident safety.
- CNAs must report to nurse when taking a break to ensure appropriate staffing is on the secured unit.
- Nurses must inform other nurses on shift when they are taking their break and make sure the CNAs are aware, so they know who to contact if there are any issues while nurse is on break.
- In-services will be completed with staff prior to working shift on secured unit.
- Administrator started in services with secured unit nurses to ensure they are doing walking rounds at the beginning and the end of each shift to check the functioning of alarms and doors.
- Completing a head count at the beginning and end of each shift and report any issues found immediately.
- In-services will be completed prior to working shift on secured unit.
- Administrator and other department managers started Inservice on elopement.
- Facility must follow policy and procedure regarding elopement.
- Establish a monitoring system until risk has resolved and assign staff to sit one on one with resident until risk resolved.
- All nurses will be in serviced over changes to elopement policy and monitoring system prior to working shift.
- Elopement policy and procedure were revised to state a staff will sit one on one with resident until the risk of elopement has resolved.
- One on one form has been created, and staff must follow guidelines on monitoring form.
- Guidelines include staff must always remain within arm's reach, resident must remain in line of sight continuously, document observations every 15 minutes, report any changes in behavior to charge nurse.
- Administrator started in services with all staff and make sure staff is in serviced prior to starting shift.
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