Sandpiper Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Mount Pleasant, South Carolina.
- Location
- 1049 Anna Knapp Boulevard, Mount Pleasant, South Carolina 29464
- CMS Provider Number
- 425146
- Inspections on file
- 21
- Latest survey
- April 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Sandpiper Post Acute during CMS and state inspections, most recent first.
Multiple rooms had extensive wall damage and doors that could not open fully, resulting in scuff marks and restricted access for several residents. The Maintenance Director confirmed the need for repairs and acknowledged that the facility's daily checklist and work order system did not prevent these deficiencies.
The facility did not have or follow up-to-date menu spreadsheets for portion sizes and therapeutic diets, resulting in several residents receiving meals that did not match their prescribed dietary needs. Staff relied on outdated menus and verbal instructions, and the general menus lacked details for therapeutic diets and portion sizes. The kitchen manager and registered dietitian confirmed that menu guidance was incomplete and inconsistently applied.
Staff did not post required Enhanced Barrier Precaution (EBP) signage or consistently use appropriate PPE, such as gowns and gloves, when providing direct care to multiple residents with indwelling devices or wounds. Observations showed that staff entered rooms and performed high-contact care activities without following EBP protocols, despite facility policy and confirmation from the DON and Infection Preventionist that these precautions were required.
The facility did not ensure that eligible residents were offered updated pneumococcal vaccinations according to CDC recommendations. Several residents over age 65 either received incomplete vaccine series or were not offered the recommended updated vaccines at the appropriate intervals. Staff interviews confirmed that there was no follow-up on vaccine updates, and the admission process did not adequately address the need for current pneumococcal immunizations.
A resident with a history of anoxic brain damage who had been receiving hospice care improved and revoked hospice services. Despite this significant change, staff completed only a quarterly MDS assessment instead of the required significant change assessment, as staff were unaware of the regulatory requirement.
The facility failed to accurately code the MDS for two residents, one of whom was on hospice care but not coded for a terminal prognosis, and another whose cognitive status was incorrectly documented as rarely or never understood despite evidence of intact cognition. The MDS Director did not verify information before submission and was unaware of the requirements for hospice coding, with no specific MDS accuracy policy in place.
A resident with end stage renal disease, a G-tube, CVC, and CPAP was admitted, but the baseline care plan developed within 48 hours was incomplete and inaccurate. The care plan listed the wrong type of dialysis and did not include interventions for the G-tube or CPAP, as confirmed by LPN, Infection Preventionist, and DON review.
A resident with a stage three pressure ulcer and multiple sclerosis was not provided with a physician-ordered ROHO cushion in his wheelchair, as required by his care plan. Despite documentation and staff awareness of the order, multiple observations and interviews confirmed the cushion was not in use, and nursing staff did not ensure the intervention was implemented.
A resident's care plan was not updated after the individual revoked hospice services, had a G-tube removed, and no longer required enhanced barrier precautions. Despite these significant changes, the care plan continued to include outdated interventions related to hospice, tube feeding, and EBP. Staff interviews and record reviews confirmed the care plan was not revised to reflect the resident's current needs.
A resident with severe cognitive impairment and multiple medical conditions experienced significant weight loss, but the facility did not consistently reweigh the resident, notify the RD, or provide nutritional supplements as required by policy. Instead, a psychotropic medication was prescribed for weight loss without prior evaluation or use of nonpharmacological interventions, and staff interviews revealed a lack of communication and process for addressing weight loss.
Two residents requiring dialysis care did not receive appropriate Enhanced Barrier Precautions during direct care, and staff failed to maintain accurate physician orders and care plan documentation. One resident with a central venous catheter did not have EBP signage or proper PPE use by staff, while another had outdated care plan interventions and continued documentation for a peritoneal dialysis site that had been removed. The DON and Infection Preventionist confirmed these deficiencies in care and documentation.
A resident with multiple cardiac and renal diagnoses received antihypertensive and related medications without consistent documentation of required blood pressure and heart rate monitoring prior to administration, despite physician orders to hold these medications if certain parameters were not met. Nursing staff interviews confirmed awareness of the monitoring requirements, but vital signs were not regularly documented in the EMR before medication administration, resulting in a failure to ensure medications were given as prescribed.
Two residents received incorrect medications during a medication pass, resulting in a 6.67% error rate. One resident was given both a multivitamin with iron and a separate iron supplement, while another received a lower-than-ordered dose of Vitamin D due to incorrect medication selection and administration by LPNs. The DON confirmed the errors after review.
Nursing staff did not consistently document or initial narcotic counts at shift changes for all medication carts reviewed, as required by facility policy. Both on-coming and off-going nurses failed to record the number of narcotic cards or confirm the count on multiple occasions, and some staff were unaware of the documentation requirements. The DON confirmed that narcotic sheets contained blanks and that staff are expected to count and document narcotics at each shift change.
Two residents receiving dialysis care had inaccurate documentation in their medical records. One resident with a CVC had staff documenting assessments for bruit and thrill, which are only relevant for AV fistulas, while another resident had documentation of gentamicin application to a PD catheter site that no longer existed. Nursing staff and facility leadership confirmed the documentation did not accurately reflect the care provided.
The facility did not ensure that the previous three years of surveys, complaint investigations, and plans of correction were accessible to residents, families, or visitors. The survey book was missing required documentation from the past three years, and the Administrator and DON confirmed it had not been updated.
A nurse left a medication cart unattended with the EMAR open, revealing multiple residents' information, contrary to the facility's PHI policy. The LPN admitted to knowing the policy but failed to secure the screen due to being overwhelmed. The DON emphasized the expectation for staff to protect patient information.
The facility failed to assess, supervise, and provide proper safety protocols for residents that smoke, leading to Immediate Jeopardy at F689. Two residents were observed smoking unsupervised, contrary to the facility's policy. Staff were unaware of residents' smoking status and procedures, and the smoking area lacked proper safety measures.
The facility failed to conduct annual performance reviews for three CNAs. Instead, CNAs received a 2% raise if they had no disciplinary actions. The facility lacked a specific policy for CNA performance reviews, and the Administrator confirmed that annual reviews will be implemented moving forward.
The facility failed to ensure proper storage and timely disposal of medications in multiple medication and treatment carts, as well as medication rooms. Expired and improperly stored medications were found, and these findings were confirmed by various nursing staff.
The report identifies deficiencies in food quality and kitchen sanitation, including resident complaints about the taste and presentation of food, improper storage of food items, and kitchen staff not wearing beard guards. The kitchen showed signs of wear and tear, and meal service was often delayed, affecting the overall dining experience for residents.
The facility failed to ensure that kitchen staff wore beard and hair restraints while handling food and did not properly store, label, date, and discard expired foods. Observations revealed multiple instances of non-compliance with facility policies and FDA Food Code guidelines.
The facility failed to provide adequate infection surveillance, tracking, and trending, and staff did not adhere to proper infection control protocols. Observations revealed multiple instances of staff failing to sanitize their hands between tasks and improper handling and storage of catheter bags. Additionally, the facility's infection preventionist admitted to printing logs retroactively, indicating a significant lapse in infection control practices.
The facility failed to consistently notify and involve residents and their representatives in care plan meetings. One resident's representative reported not being notified for over a year, another resident did not have a care plan meeting in months, and a third resident's representative was not informed about the resident's condition and care. The LSW and DON acknowledged the oversight and confusion in the scheduling and notification process.
A facility failed to properly position a catheter bag for a resident, leading to a deficiency. The resident's catheter bag was found on the floor, contrary to the facility's policy and care plan. Staff interviews confirmed the expectation to keep catheter bags off the floor to prevent infection control issues.
The facility failed to provide dignity to a resident by not adhering to the policy of knocking and requesting permission before entering the resident's room. The resident, who is cognitively intact, was observed on two separate occasions where staff entered her room without knocking. The DON confirmed that staff are expected to knock before entering resident rooms.
A resident with hemiplegia and hemiparesis expressed concerns about the removal of side rails from their bed without proper assessment. Despite using a trapeze bar for bed mobility and trying other measures, the resident's preference for side rails was not adequately considered. The facility's communication and documentation processes were found lacking, and there was a conflict between safety protocols and individual resident needs.
The facility failed to notify a resident's responsible party about a room change necessitated by a ceiling leak. Interviews revealed that there was no documentation or notification in the resident's medical record, despite facility policy requiring such actions.
The facility failed to prevent an altercation between two residents, one with a history of schizophreniform disorder and the other with moderate cognitive impairment. Additionally, the facility neglected to provide necessary care for a quadriplegic resident, who reported sitting in urine and feces all day and not receiving meals until dinner. The administration did not document the grievance or report the neglect allegation to the state agency promptly.
The facility failed to report a resident-to-resident altercation and an allegation of neglect to the state agency in a timely manner. One resident with schizophreniform disorder aggressively pushed their roommate out of the room and barricaded the door, while another resident with quadriplegia reported being neglected and left in urine and feces all day. Both incidents were not reported as required.
A resident with multiple diagnoses, including end-stage renal disease and cognitive communication deficit, reported not engaging in any activities because none were provided. Despite a care plan indicating in-room visits and activity provision, these were not consistently implemented. The Activities Assistant confirmed the resident's refusals were not documented, and the interim DON acknowledged the lack of documentation and follow-through.
A resident with multiple health issues reported not receiving in-room activities as per their care plan. Staff confirmed the resident's refusals were not documented, and records were lost after the Activities Director resigned. The interim DON acknowledged the need for proper documentation and individualized activity plans.
The facility failed to provide adequate ADL care to a resident dependent on staff for all ADLs. Observations over several days showed the resident in a disheveled state, wearing the same nightgown, and in need of facial and oral care. Staff interviews confirmed the neglect, with a CNA admitting to not assisting the resident with ADLs for the day.
A resident's oxygen concentrator was set at 3.5 liters per minute instead of the physician-ordered 4 liters per minute. This discrepancy was confirmed by a registered nurse who adjusted the oxygen flow. The facility's policy on oxygen administration was not followed, and no respiratory assessments were noted in the medical records.
A resident with chronic pain and multiple health conditions did not receive timely pain medication, despite expressing pain and being observed in distress. The facility staff failed to assess the pain scale and delayed administering the prescribed medication, contrary to the facility's pain management policy.
A resident who returned from the hospital did not receive their dinner meal tray due to a lack of communication between nursing staff and the kitchen. The resident, who is cognitively intact, was given two sandwiches instead, which were insufficient as they had not eaten before leaving the hospital. Meal tickets are printed at 3:00 PM, and nursing staff are responsible for notifying the kitchen if a meal tray is needed after this time.
Failure to Maintain Safe and Homelike Environment Due to Damaged Walls and Doors
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by multiple observations of physical damage and accessibility issues in resident rooms and bathrooms. Specifically, several resident rooms had extensive and deep wall scrapings along the sides of beds and across walls, while some bathroom and room doors could not open fully due to being jammed along the floor, resulting in large scuff marks. These deficiencies were observed in the rooms of eight residents, affecting their living conditions and ease of access to their bathrooms and rooms. The facility's Common Area Checklist required daily monitoring of doors, walls, trims, baseboards, and flooring, but these issues persisted. During interviews, the Maintenance Director confirmed the presence of damaged doors and walls, acknowledging that some doors had shifted and required repair or replacement, and that the walls needed to be repaired and painted. The Maintenance Director also stated that an electronic work order system was in place for staff to report concerns, but the observed deficiencies indicated that necessary maintenance services were not conducted as required.
Failure to Provide and Follow Therapeutic and Portion-Specific Menus
Penalty
Summary
The facility failed to ensure that menus met the nutritional needs of residents, were prepared in advance, followed, updated, and reviewed by a dietitian, and that they met the specific needs of each resident. Observations and interviews revealed that menu spreadsheets for portion sizes and therapeutic diets were either missing or not followed for several residents. The general menus in use did not match the planned menu spreadsheets and lacked details for therapeutic diets and portion sizes. Staff relied on old menus and verbal instructions for serving sizes, and there was no consistent documentation or guidance for preparing meals according to residents' prescribed diets. For three residents reviewed, there were discrepancies between their prescribed diets and the meals served. One resident with a pureed, renal, and large portion diet was served meals that did not align with a renal or pureed menu, and the breakfast menu did not include a pureed or renal option. Another resident on a mechanically altered, no added salt diet received a meal that did not correspond to a mechanically altered menu. A third resident on a carbohydrate-controlled, no added salt diet was served a meal that did not reflect a CCHO menu. In each case, the general menu used did not provide for the specific dietary needs or textures required by the residents' orders. Interviews with the kitchen manager and registered dietitian confirmed that menu spreadsheets for the current menus were still being developed, and staff were using old menus or making substitutions without proper documentation for side dishes or portion sizes. The kitchen manager admitted to not having clear spreadsheets for staff to follow and instead provided verbal instructions on serving sizes. The lack of up-to-date, detailed menus and portion guidance led to inconsistencies in meal preparation and serving for residents with therapeutic and texture-modified diets.
Failure to Post Enhanced Barrier Precaution Signage and Ensure PPE Use
Penalty
Summary
The facility failed to follow its own policy regarding Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or open wounds. According to the facility's policy, EBP signage indicating the required personal protective equipment (PPE) must be posted outside the rooms of residents with wounds, urinary catheters, G-tubes, or those receiving dialysis, regardless of MDRO colonization. Surveyors observed that for 13 residents with such conditions, there was no EBP signage posted on their doors or walls to indicate the necessary PPE for direct care activities. Multiple observations confirmed the absence of EBP signage for residents with chronic kidney disease, end stage renal disease, neuromuscular dysfunction of the bladder, gastroesophageal reflux disease with G-tube, pressure ulcers, and other relevant diagnoses. In several instances, staff members, including LPNs and CNAs, provided direct care to these residents without donning the appropriate PPE as required by EBP protocols. For example, an LPN was observed handling a central venous catheter dressing without gloves, and a CNA changed a resident's brief while only wearing gloves and not a gown. Interviews with the Director of Nursing and the Infection Preventionist confirmed that residents with dialysis, wound care, urinary catheters, and G-tubes were supposed to be on EBP, and staff were expected to wear gowns and gloves during direct resident contact. Despite this, the required signage was not present, and staff did not consistently use the appropriate PPE during high-contact care activities for these residents.
Failure to Offer Updated Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal vaccinations in accordance with CDC recommendations to five residents over the age of 65, as required by facility policy and national standards. Record reviews showed that these residents either received only partial pneumococcal vaccination series or had not been offered the recommended updated vaccines, such as PCV15, PCV20, or PCV21, at the appropriate intervals after previous doses of PPSV23 or PCV13. One resident had previously refused pneumovax vaccinations, but there was no evidence that updated vaccine options were offered as per current guidelines. Interviews with facility staff, including the Regional Director of Clinical Services and the Infection Preventionist, revealed that the facility did not follow up on pneumococcal vaccine updates. The staff relied on providers to order vaccines and did not ensure that residents were offered vaccinations in line with CDC recommendations. The admission process did not adequately assess or act upon the need for updated pneumococcal vaccinations, resulting in missed opportunities for residents to receive appropriate immunizations.
Failure to Complete Significant Change MDS After Hospice Revocation
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident who revoked hospice services following an improvement in condition. According to the Resident Assessment Instrument (RAI) manual, a significant change in status assessment (SCSA) is required when a resident discontinues hospice care. Documentation showed that the resident, who had a history of anoxic brain damage and was initially admitted to hospice, later stabilized and gained weight, leading to the revocation of hospice services. Despite this change, only a quarterly MDS assessment was completed, not the required significant change assessment. Interviews with facility staff revealed a lack of awareness regarding the requirement to complete a significant change assessment when a resident revokes hospice services. The MDS Director confirmed that the resident discontinued hospice but stated they were unaware of the need for a significant change assessment. The Director of Nursing also confirmed that the assessment had not been completed. This oversight was identified through record review, staff interviews, and review of the resident's electronic medical record.
Inaccurate MDS Coding for Terminal Prognosis and Cognitive Status
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to assessment accuracy. For one resident with an anoxic brain injury and blood clots, who was readmitted and placed on hospice care, the significant change MDS did not reflect the resident's terminal prognosis of six months or less, despite the presence of a physician-signed Certification of Terminal Illness and an active hospice order. The MDS Director stated that the hospice documentation was not reviewed because it was not uploaded to the electronic medical record until after the assessment was completed, and was unaware that hospice care required a terminal diagnosis of six months or less. For another resident with a history of senile degeneration of the brain and cognitive communication deficit, the quarterly MDS was inaccurately coded as "Rarely or Never Understood" and omitted required cognitive assessment scores, despite previous and subsequent assessments indicating moderate to intact cognition. The MDS Director acknowledged the error, stating the resident was cognitively intact at the time and that the information was not verified before submission. The facility did not have a specific MDS accuracy policy in place, relying solely on the RAI manual.
Failure to Develop Accurate and Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that a baseline care plan was accurate and complete within 48 hours of admission for one resident. According to the facility's policy, a baseline care plan should be developed for each resident within 48 hours of admission and should include instructions needed to provide effective, person-centered care. Review of the resident's admission record revealed diagnoses including end stage renal disease (ESRD), and observations showed the resident had a gastrostomy tube (G-tube), a central venous catheter (CVC), and a continuous positive airway pressure (CPAP) machine. However, the care plan in the electronic medical record (EMR) only included a focus for dialysis with interventions for peritoneal dialysis, which was incorrect, as the resident was receiving hemodialysis via a CVC. Further review and interviews confirmed that the care plan lacked documentation for the resident's G-tube and CPAP use. The LPN verified that the care plan did not reflect the correct type of dialysis and omitted the G-tube and CPAP. The Infection Preventionist/Unit Manager and the Director of Nursing also confirmed these omissions and inaccuracies in the care plan, verifying that the resident's care needs were not properly documented as required by facility policy.
Failure to Implement Care Plan Intervention for Pressure Ulcer
Penalty
Summary
The facility failed to implement a person-centered, comprehensive care plan with measurable goals for a resident with a stage three pressure ulcer. The resident, who had multiple sclerosis, muscle weakness, and moderate cognitive impairment, was dependent on staff for transfers and mobility. Physician orders and the care plan specified the use of a ROHO cushion in the resident's wheelchair to address the risk of skin breakdown and promote healing of pressure ulcers. However, multiple observations and interviews confirmed that the resident was not provided with the required cushion while seated in either his old or new wheelchair. Staff interviews revealed that although the order for the ROHO cushion was present in the electronic medical record, it was not included on the Medication Administration Record or Treatment Administration Record, and nursing staff were not ensuring the intervention was in place. The resident himself confirmed on several occasions that he did not have a cushion in his wheelchair, and this was corroborated by LPNs and the unit manager during direct observation. The Director of Nursing stated that staff were expected to follow care plans and physician orders, but this was not done in this case.
Failure to Update Care Plan After Significant Change in Resident Status
Penalty
Summary
The facility failed to update the comprehensive care plan for a resident after significant changes in the resident's condition and care needs. The resident, who had a history of anoxic brain injury and was previously receiving hospice services, revoked hospice care, had a gastrostomy tube (G-tube) removed, and no longer required enhanced barrier precautions (EBP). Despite these changes, the care plan continued to reflect outdated interventions, such as coordination with hospice staff, G-tube care, and EBP related to the feeding tube. The care plan was not revised to reflect the resident's current status, including the absence of tube feedings and the discontinuation of hospice services. Interviews with facility staff confirmed that the care plan was not updated following the resident's revocation of hospice services and removal of the G-tube. Observations showed the resident was alert, able to communicate, and independently feeding himself a regular meal without swallowing issues. The failure to revise the care plan after these significant changes was confirmed by both the Director of Nursing and the MDS Director, indicating a lapse in the facility's process for timely care plan updates.
Failure to Investigate and Address Significant Weight Loss
Penalty
Summary
The facility failed to properly investigate and address significant weight loss in a resident with multiple medical conditions, including severe cognitive impairment, non-Alzheimer's dementia, schizophrenia, and dysphagia. Despite a documented 8% weight loss over three months, there was no evidence that the facility followed its own policy requiring immediate reweighing and notification of the dietitian when a significant weight change was identified. The resident's weights were inconsistently measured using different methods, and the Registered Dietitian (RD) noted that reweighing and a deeper investigation into the cause of weight loss should have occurred sooner. The resident was not provided with nutritional supplements despite consistently low meal consumption and no orders for supplementation were found in the medical record. The care plan identified the resident as being at risk for malnutrition and included interventions such as providing supplements and RD evaluation, but these interventions were not implemented. The RD confirmed that she had not recommended supplements because she was waiting for a reweight and further investigation, which had been delayed. Additionally, a psychotropic medication (Mirtazapine) was prescribed to address the resident's weight loss without prior evaluation or implementation of nonpharmacological interventions, and the RD was not consulted before this decision. Interviews with facility staff, including the RD, Nurse Practitioner (NP), and Director of Nursing (DON), revealed a lack of communication and process for identifying and responding to weight loss. The DON acknowledged there was no established process for identifying residents at risk for weight loss and was unaware of discrepancies in the resident's diet order and the absence of menu extensions for therapeutic diets.
Failure to Ensure Safe Dialysis Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for residents requiring such services by not ensuring the use of Enhanced Barrier Precautions (EBP) during direct care, lacking proper physician orders for dialysis, and documenting inaccurate interventions in care plans. For one resident with chronic kidney disease and a central venous catheter (CVC) for dialysis access, staff did not post EBP signage or use gloves during dressing observation, and the care plan inaccurately documented monitoring for bruit and thrill, which are not applicable to CVCs. The unit manager confirmed that EBP should have been implemented but was not. Another resident with a history of end-stage renal disease had no physician order for dialysis in the electronic medical record, and the care plan included interventions for peritoneal dialysis (PD) despite the PD catheter having been removed prior to admission. Staff continued to document and apply gentamicin ointment to a nonexistent PD site, and the care plan lacked focus and interventions for hemodialysis. Both the DON and Infection Preventionist confirmed the inaccuracies in documentation and the failure to implement EBP for residents with dialysis access devices.
Failure to Monitor Blood Pressure Parameters Before Administering Antihypertensive Medications
Penalty
Summary
The facility failed to ensure that a resident’s drug regimen was free from unnecessary drugs by not following physician-ordered parameters for blood pressure monitoring prior to administering antihypertensive and related medications. The resident, who had diagnoses including atrial fibrillation, hypertensive chronic kidney disease, edema, and congestive heart failure, was prescribed several medications with specific instructions to hold administration if systolic blood pressure (SBP) was below 100 or if heart rate was below 50. Despite these orders, medication administration records (MARs) for multiple months showed that the medications were given without consistent documentation of SBP or heart rate prior to administration. Review of the resident’s care plan and physician orders indicated that vital signs were to be checked every shift while the resident was on skilled care, and that medications such as Amlodipine, Furosemide, Losartan, and Carvedilol were to be held based on specific blood pressure and heart rate parameters. However, MARs and blood pressure summaries revealed that vital signs were not consistently documented before medication administration, and in many instances, there was no record of the required monitoring. Interviews with nursing staff confirmed that while they were aware of the need to check vitals and hold medications as ordered, the documentation was incomplete or missing in the electronic medical record (EMR). The Director of Nursing acknowledged that medication orders should be followed and that parameters for holding medications must be adhered to, but confirmed that regular vital checks prior to administration were not documented for this resident. The lack of adherence to prescribed monitoring protocols and incomplete documentation led to the administration of medications without ensuring the resident met the required parameters, constituting a failure to prevent unnecessary drug administration.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate during a medication pass observation. In one instance, a nurse administered both a multivitamin with iron and a separate iron replacement tablet to a resident, despite the physician's order for only one of each. The nurse acknowledged that this could result in the resident receiving too much iron and confirmed that the medication was taken from the bottle on the medication cart without verifying with the physician. In another case, a nurse administered a Vitamin D tablet at a dosage of 10 mcg instead of the prescribed 100 mcg to a different resident. Upon review, the nurse could not locate the correct dosage in the medication cart and realized that two tablets of a 50 mcg dosage should have been given to meet the physician's order. The Director of Nursing was informed of the two medication errors out of 30 opportunities, confirming the facility's medication error rate exceeded the acceptable threshold.
Failure to Document and Verify Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to ensure that narcotic counts were properly documented and initialed by both the on-coming and off-going nurses at each shift change for all eight medication carts reviewed. According to the facility's policy, nursing staff are required to count controlled medication inventory at the end of each shift, reconcile the inventory count, and document their initials to confirm the count. However, multiple instances were identified where either the on-coming or off-going nurse, or both, did not initial the narcotic count or document the number of narcotic cards present in the narcotic drawer as required. These lapses were observed across various medication carts and on multiple dates, with missing documentation and initials noted on the narcotic sheets. Interviews with nursing staff revealed a lack of awareness or adherence to the documentation requirements, with one LPN stating that the omission was a mistake due to unfamiliarity with the shift. Another nurse did not provide an explanation for the missing documentation. The Director of Nursing confirmed the presence of blanks in the narcotic sheets and acknowledged that staff are expected to count and document the narcotics at each shift change. The failure to consistently document and verify narcotic counts as per policy was observed throughout the facility.
Inaccurate Documentation of Dialysis Care and Site Management
Penalty
Summary
The facility failed to ensure accurate documentation of dialysis care for two residents receiving dialysis treatments. For one resident with chronic kidney disease and a central venous catheter (CVC) for dialysis access, physician orders required monitoring for bruit and thrill, which are only present with an arteriovenous (AV) fistula. Nursing staff documented the presence of bruit and thrill in the medical administration record (MAR) despite knowing the resident had a CVC, not an AV fistula, and that such assessments were not applicable. Staff acknowledged the documentation was inaccurate but continued to record it due to limitations in the documentation system and lack of clarification with management. For another resident with end stage renal disease, physician orders required topical application of gentamicin to a peritoneal dialysis (PD) catheter site. However, the PD catheter had been removed prior to admission, and the site was healed. Nursing staff continued to document the application of gentamicin to the non-existent PD catheter site, despite being aware that the order was no longer appropriate. Facility leadership confirmed that documentation for both residents was inaccurate and did not reflect the actual care provided.
Failure to Provide Access to Survey Results and Plans of Correction
Penalty
Summary
The facility failed to make the previous three years of surveys, complaint investigations, and any plans of correction readily accessible to residents, families, or visitors. During a facility tour, it was observed that the survey book located at the entrance to the activity room did not contain any surveys, certifications, complaint investigations, or plans of correction from 2022 to the present. Review of the Certification and Survey Provider Enhanced Reporting (CASPER) report confirmed that multiple surveys and complaint investigations, some of which were substantiated and resulted in plans of correction, had occurred during this period. In an interview, the Administrator and DON acknowledged that the survey book had not been updated with the required information for the past three years.
Failure to Secure Electronic Medication Administration Record
Penalty
Summary
The facility failed to protect residents' private health information for three of eight residents. During an observation, a nurse left a medication cart unattended while administering medications, with the Electronic Medication Administration Record (EMAR) still open on the computer screen, revealing multiple residents listed. The facility's policy on Protected Health Information (PHI) requires that the use or disclosure of PHI be limited to the minimum necessary to accomplish the intended purpose. During an interview, the LPN acknowledged the policy to lock the screen when stepping away but admitted to leaving it open due to being overwhelmed with tasks. The Director of Nursing (DON) stated that staff are expected to protect patient information and have options to secure the screen, such as closing the laptop or pressing the privacy HIPAA button.
Failure to Supervise and Ensure Safety for Smoking Residents
Penalty
Summary
The facility failed to assess, supervise, and provide proper safety protocols for residents that smoke, leading to Immediate Jeopardy (IJ) at F689. Two residents, R123 and R101, were observed smoking unsupervised, which is against the facility's smoking policy. R123 was found smoking alone outside the facility without proper documentation of his smoking assessment, and R101 admitted to providing cigarettes to other residents and keeping smoking materials in his room, contrary to the facility's policy that prohibits residents from keeping such items in their possession. R123's records revealed that he had not been assessed for smoking prior to a specific date, and his care plan did not reflect his current smoking status. Additionally, the facility's smoking area lacked proper safety measures, such as ashtrays, and was littered with cigarette butts. Staff interviews indicated a lack of awareness and adherence to the facility's smoking policy, with some staff members unaware of residents' smoking status and the procedures for supervising smoking activities. The facility was in the process of transitioning to a smoking facility but had not yet implemented the necessary safety protocols. This led to residents smoking unsupervised and without proper safety measures in place, creating a hazardous environment. The facility's failure to ensure residents' safety while smoking and to adhere to its own policies resulted in the identification of Immediate Jeopardy and substandard quality of care at F689.
Removal Plan
- Education provided to all residents known to smoke or have a history of smoking. Process for keeping cigarettes at reception desk not keeping them on their person reviewed as well as process to sign out with receptionist prior to going out to smoking area and that staff would accompany them and supervise.
- Smoking evaluations will be completed for all residents known by staff who currently smoke or have a history of smoking. Previous smoking evaluations were noted to be conflicting related to safety status while smoking.
- 100% audit on residents known to smoke or have a history of smoking complete to ensure care plans accurately reflect current smoking evaluation.
- Education sent to all staff via COVR message to ensure understanding of procedure for residents who smoke and that they must sign out at a reception and a staff member will accompany them out to smoking area.
- Education provided to all Resident Representatives via message to ensure understanding of procedure for residents that a staff member will accompany them out to the smoking area.
- Education to resident who have a history of smoking to ensure that all are understanding the process for smoking: go to receptionist and sign yourself out and get your smoking items if you have them and you will be accompanied out to smoking area by a staff member to ensure your safety.
- Education provided to all staff to ensure understanding of process above and that staff member must accompany resident to smoking area and sit with them and ensure they are safe. A smoking apron will be taken out with them.
- Any resident noted smoking any concern of safety related to holding cigarettes, dropping them etc. will be reported to Administrator and Director of Nursing (DON) immediately and smoking evaluation will be completed to ensure current status is correct.
- Education/notification will be sent to all RR's via COVR message to inform of above process and that smoking will be supervised until smoking program is implemented.
- All smoking materials have been gathered by Admin Staff and are located at the reception desk in a locked box to be given to resident at the time they sign out and returned to lock box upon reentry of facility.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that three certified nursing assistants (CNAs) received their annual performance reviews. This deficiency was identified through record reviews and interviews. The Regional Director revealed that the facility does not have a specific policy for CNA performance reviews. Personnel files for three CNAs showed that their annual performance reviews were not completed in the past year. Interviews with the Regional Director of Clinical Services and the Administrator confirmed that CNAs do not receive performance reviews but are given a 2% raise if they have not received any disciplinary actions over the year. The Administrator stated that performance reviews will be conducted annually moving forward, with Human Resources notifying CNAs when their yearly marks are approaching.
Medication Storage and Expiration Issues
Penalty
Summary
The facility failed to ensure that medications were properly stored in multiple medication and treatment carts, as well as medication rooms. During an inspection of the 400 Hall Treatment Cart, it was found that there were opened and in-use tubes of TheraHoney Gel and Med Honey Gel, which were labeled for single use only. Additionally, expired medications such as Hydrogen Peroxide, PVP Ready Scrub Solution, Multidex tube, and Sterile Normal Saline were found. These findings were confirmed by two Registered Nurses (RNs) who indicated that the night nurse was supposed to check the cart. Similar issues were found in the 400 Hall Medication Cart 2, where an opened and undated Fluticasone Propionate and Salmeterol Inhalation Powder was discovered, which should have been discarded one month after opening the foil packet. This was confirmed by an RN during the inspection. The 300 Hall Treatment Cart also contained an opened container of Sterile Water in an unlocked storage container, which was confirmed by another RN. In the 100 Hall Medication Room, expired medications such as Magnesium Citrate, Ibuprofen, and ProSource No Carb packets were found, and these findings were confirmed by an LPN. The 100 Hall Medication Cart 1 had an unopened vial of Lantus that was not refrigerated as required, a bottle of Iron Supplement Liquid with a brown sticky substance, and expired ProSource No Carb packets. Additionally, an opened and in-use vial of Lantus was not dated when opened and was stored improperly with eye drops. Timolol Maleate Ophthalmic Solution and Budesonide Inhalation Suspension were also found undated and stored outside their foil envelopes. These findings were confirmed by an LPN. The 100 Hall Treatment Cart contained expired medications such as Triple Antibiotic Ointment, Cicloprox Shampoo, and an opened and uncapped Hydrocortisone Valerate Cream. These findings were confirmed by another LPN. The Hall 200 Treatment Cart was found unlocked and unmanned, containing expired medications such as Mometasone Furoate, Nystatin-Triamcinolone Acetonide Cream, Betamethasone Dipropionate cream, Triamcinolone Acetonide, and MediHoney Hydrogel. This was confirmed by an LPN and the Regional Nurse Consultant. The Hall 200 Medication Room contained expired Banatrol Plus and Beneprotein packets, confirmed by an LPN. The Hall 200 Medication Cart 1 had opened Lantus Solostar and Novolog N Flexpen with no expiration date or date of opening, confirmed by an LPN. The Hall 200 Medication Cart 2 contained an expired bottle of Bisacodyl, confirmed by another LPN. The Hall 300 Medication Cart 2 had an in-use Fluticasone Propionate/Salmeterol Diskus dated as opened but not discarded after one month as required. This was confirmed by an LPN.
Deficiencies in Food Quality and Kitchen Sanitation
Penalty
Summary
The report identifies several deficiencies related to the quality and safety of food services in the facility. Multiple residents expressed dissatisfaction with the taste, presentation, and temperature of the food. Specific complaints included food tasting like 'frozen garbage,' being undercooked, and generally not being palatable. One resident even reported spending extra money on external food deliveries due to the poor quality of meals provided by the facility. Observations confirmed that the food served was not appetizing, with issues such as undercooked rice and bland vegetables being noted during a test tray evaluation. In the kitchen, several sanitation and safety issues were observed. Male kitchen staff were not wearing beard guards, and the facility was reportedly out of them. The kitchen had visible signs of wear and tear, including cracked tiles and water damage on the ceiling, which also showed signs of mold. While the temperature logs for food and equipment were within normal ranges, the overall cleanliness and maintenance of the kitchen were subpar. Additionally, the dietary pantries in various wings contained expired and improperly stored food items, including freezer-burned hot dogs and ice cream, and a dirty refrigerator. The facility's dietary management also showed signs of systemic issues. The Dietary Manager was new and acknowledged ongoing problems, including late meal service and the need to address concerns raised by the resident council. The ombudsman confirmed that meal times had been a persistent issue for several months, with residents often being served meals up to an hour late. These deficiencies collectively indicate a failure to provide safe, palatable, and properly timed meals to residents, compromising their overall dining experience and potentially their health.
Failure to Ensure Proper Food Handling and Storage
Penalty
Summary
The facility failed to ensure that kitchen staff wore beard and hair restraints while cooking, preparing, or assembling food. Observations revealed multiple instances where male kitchen staff were not wearing beard guards, despite facility policies requiring such attire. The Cook admitted that the facility was out of beard guards and did not consider using hair nets as an alternative. The Dietary Manager confirmed that all male kitchen staff are required to wear facial covers while handling food, but this was not adhered to during the survey period. Additionally, the facility failed to properly store, label, date, and discard expired foods. Observations in various dietary pantries revealed opened and unlabeled containers of food, including Chinese food, bologna, cheese slices, hot dogs, and chocolate ice cream. The refrigerator in one pantry was found to be dirty and sticky from spilled juice and food. These findings indicate a lack of compliance with the facility's policies on food storage and safety, as well as the FDA Food Code guidelines.
Infection Control Deficiencies
Penalty
Summary
The facility failed to provide adequate infection surveillance, tracking, and trending, as well as monitoring for outbreaks. The Infection Control Log from June 2023 through January 2024 revealed missing individual resident reports of infection, and the print date for all six months was 4/15/2024. Additionally, February and March 2024 had no information in the corresponding months of the book. The facility's infection preventionist, who started in January 2024, admitted to printing the logs on 4/15/2024 to show that they were looking at the data, but confirmed that the tracking for February and March was not done. This lack of proper documentation and tracking indicates a significant lapse in the facility's infection control practices. During an observation on 4/17/2024, a laundry staff member was seen handling soiled clothes without wearing a gown, and her scrub jacket touched both clean and dirty laundry. This was confirmed by the laundry aid, who acknowledged that she should have worn a gown on the soiled side. The laundry manager also confirmed that staff are required to wear gowns when handling soiled laundry and that staff clothing should not touch residents' laundry. This failure to adhere to proper infection control protocols further highlights the deficiencies in the facility's infection prevention and control program. Additional observations revealed multiple instances of staff failing to sanitize their hands between tasks, such as handling food trays and assisting residents. For example, a CNA was observed pulling a tray from a cart, entering and exiting multiple rooms, and assisting residents without sanitizing his hands. Furthermore, there were issues with the proper handling and storage of catheter bags, with several instances of catheter bags being placed on the floor or trash cans, and staff not wearing appropriate PPE when providing catheter care. These observations indicate a widespread lack of adherence to infection control protocols, putting residents at risk of infections and other complications.
Deficiencies in Care Plan Meeting Notifications and Involvement
Penalty
Summary
The report identifies deficiencies in the facility's process for involving residents and their representatives in care plan meetings. Resident #98, who has a diagnosis of Parkinson's disease and moderate cognitive impairment, was not consistently included in care plan meetings. The resident's representative reported not being notified of care plan meetings for over a year, despite previously being actively involved. The Licensed Social Worker (LSW) acknowledged the oversight and admitted to not being aware of the schedule for care plan meetings. The Interim Director of Nursing (DON) confirmed that care plan meetings should be conducted quarterly and that the LSW is responsible for notifying residents and their representatives, but could not verify if this was being done consistently. Resident #138, who is cognitively intact, also reported not having had a care plan meeting in months and not being informed about changes in care. The LSW could not recall the last care plan meeting for this resident and admitted that the resident was overdue for a meeting. The DON reiterated that care plan meetings are an opportunity for the interdisciplinary team to discuss the resident's needs and preferences, but was unaware that these meetings were not being conducted as required. Additionally, Resident #273's representative reported not being invited to care plan meetings and expressed concerns about the resident's wound care and overall treatment. The representative noted that the resident was sent to the hospital with severe sepsis and MRSA, and that there were issues with communication and notification about the resident's condition and care. The LSW and DON both acknowledged the importance of care plan meetings and the need for proper documentation and communication, but there was confusion and inconsistency in the scheduling and notification process.
Improper Positioning of Catheter Bag
Penalty
Summary
The facility failed to properly position the catheter bag for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including retention of urine and presence of urogenital implants, had an indwelling catheter. The facility's policy required that catheter bags be kept off the floor to prevent urinary catheter-associated complications, including urinary tract infections. However, during an observation, the resident's catheter bag was found lying on the floor under the bed. Interviews with staff, including a Registered Nurse, Licensed Practical Nurse, Infection Control Preventionist, Interim Director of Nursing, and the Administrator, confirmed that the catheter bag should not be on the floor and should be properly anchored and positioned to prevent infection control issues. The resident's care plan included interventions to provide catheter care, empty the catheter every shift, and keep the catheter anchored to prevent trauma. Despite these measures, the catheter bag was observed on the floor, indicating a failure to adhere to the facility's policy and the resident's care plan. Staff interviews revealed that while there was an understanding of the proper positioning of catheter bags, there were instances where the bags were found on the floor, and education was provided when such issues were observed. The Administrator noted that some residents might move the catheter bags themselves, and in such cases, residents were educated on infection control issues and encouraged to keep the catheter off the floor.
Failure to Provide Dignity by Not Knocking Before Entering Resident's Room
Penalty
Summary
The facility failed to provide dignity to Resident 129 by not adhering to the policy of knocking and requesting permission before entering the resident's room. Resident 129, who is cognitively intact with a BIMS score of 15 out of 15, was observed on two separate occasions where staff entered her room without knocking. On one occasion, maintenance staff and an LPN entered the room without knocking, and on another occasion, a CNA entered without knocking and acknowledged that he should have knocked first. The Director of Nursing confirmed that staff are expected to knock before entering resident rooms.
Failure to Properly Assess and Accommodate Resident's Needs and Preferences
Penalty
Summary
The deficiency involves the failure to properly assess and accommodate the needs and preferences of a resident with significant medical conditions. The resident, who has hemiplegia and hemiparesis following a cerebral infarction, expressed concerns about the removal of side rails from their bed without proper assessment. The resident mentioned that they have been using a trapeze bar for bed mobility for a long time and have only one good arm to use it. Despite trying other measures, these alternatives did not work effectively for the resident. The resident's preference for the side rails was not adequately considered, leading to dissatisfaction and potential safety concerns. The report also highlights the resident's active participation in community activities, such as going to the store and visiting their son, which indicates a level of independence and mobility that should be supported within the facility. However, the resident's concerns about the side rails were not communicated to the Risk Nurse Manager, and there was a lack of documentation regarding the resident's preferences and the rationale for removing the side rails. This oversight suggests a gap in communication and documentation processes within the facility. Additionally, the report includes an interview with the Regional and Rehab Director, who acknowledged that the resident was assessed as safe to use side rails but emphasized the need to prove that other measures were tried before considering the reinstallation of side rails. The director expressed concerns about the safety of side rails due to a past incident involving another resident. This indicates a potential conflict between safety protocols and individual resident needs, which was not adequately addressed in this case, leading to the deficiency.
Failure to Notify Responsible Party of Room Change
Penalty
Summary
The facility failed to notify the responsible party of Resident 273 about a room change. The resident was admitted with multiple diagnoses, including fractures and cognitive communication deficit. The room change was necessitated by a ceiling leak that led to the ceiling caving in. However, the responsible party was not informed about this change, as confirmed by the resident's responsible party during an interview. The facility's policy requires notification of room changes to the resident's representative, but this was not followed in this instance. Interviews with the Social Services Director and the Short Term Social Services revealed that there was no documentation or notification regarding the room change in the resident's medical record. The Social Services Director confirmed that typically, both the resident and the responsible party are informed of room changes, especially if there is a safety concern. However, in this case, the responsible party was not notified, and no notes were made in the medical record to document the room change or the reason behind it.
Failure to Prevent Resident Altercation and Neglect of Care
Penalty
Summary
The facility failed to prevent a resident-to-resident altercation and neglected to provide care for a resident. The incident involved Resident 160 (R160) and Resident 117 (R117). R160, who has a history of schizophreniform disorder and moderate cognitive impairment, exhibited aggressive behavior towards R117, pushing her out of the room and barricading the door. Despite previous documentation of R160's problematic behaviors, the facility did not take adequate measures to prevent the altercation. R117, who also has moderate cognitive impairment, was left feeling scared and uncomfortable, and no proper assessment was conducted after the incident as required by the facility's policy. The facility's staff, including the Unit Manager and Licensed Practical Nurse (LPN), acknowledged the ongoing issues between the two residents but failed to take appropriate action to separate them or address the root causes of the conflict effectively. Additionally, the facility neglected to provide care for Resident 58 (R58), who is quadriplegic and dependent on staff for all activities of daily living (ADLs). On a specific date, R58 did not receive necessary care, including bowel and bladder continence, turning and repositioning, and feeding. R58 reported sitting in urine and feces all day and not receiving any meals until dinner. Despite filing a grievance with the facility, the administration did not document the grievance or report the neglect allegation to the state agency promptly. The Director of Clinical Services confirmed that the Certified Nursing Assistant (CNA) responsible for R58's care on that day was an agency staff member who is no longer allowed to return to the facility due to neglecting their duties. The facility's failure to prevent the altercation between R160 and R117 and the neglect of R58 highlights significant deficiencies in the facility's ability to protect residents from abuse and neglect. The administration's lack of timely reporting and proper documentation further exacerbates the issue, indicating a need for improved oversight and adherence to policies designed to ensure resident safety and well-being.
Failure to Report Resident Altercation and Neglect
Penalty
Summary
The facility failed to report a resident-to-resident altercation and an allegation of neglect to the state agency in a timely manner as required by federal regulation. In one instance, a resident with diagnoses including schizophreniform disorder and delirium aggressively pushed their roommate out of the room, causing the roommate to sit on the floor in fear. The aggressive resident then barricaded the door with a chair. The facility staff managed to calm the aggressive resident with medication, but the incident was not reported to the state agency because the facility believed it was only a verbal altercation, not a physical one. In another instance, a resident with quadriplegia and major depressive disorder reported that staff were disrespectful and neglected her care, leaving her in urine and feces all day. The resident stated that she did not receive any care or food until dinner time and had spoken to the Administrator about the neglect. Despite being aware of the allegations, the facility did not officially file a grievance or report the potential neglect to the state agency.
Deficiency in Activity Provision and Documentation
Penalty
Summary
Resident #138, who was admitted with multiple diagnoses including end-stage renal disease, cognitive communication deficit, and hypertensive heart disease, was found to have deficiencies in the provision of activities and engagement. Despite being cognitively intact with a BIMS score of 15, the resident reported not engaging in any activities because none were provided. The resident stated that staff only got them out of bed on dialysis days and did not bring any activities to their room. The care plan indicated that the resident should receive in-room visits at least twice per week and be provided with an activity calendar and cable channel lineup, but these interventions were not consistently implemented. The Activities Assistant (AA) confirmed that the resident often refused in-room activities but admitted that these refusals were not documented. The interim Director of Nursing (IDON) acknowledged that the resident had requested in-room activities and was aware of the refusals, which should have been documented for proper care planning. The former Activities Director had kept attendance records, but these were lost when they resigned, further complicating the situation. This lack of documentation and follow-through on the care plan led to the resident's needs not being adequately met.
Deficiency in Provision and Documentation of Resident Activities
Penalty
Summary
Resident #138, who was admitted with multiple diagnoses including end-stage renal disease, cognitive communication deficit, and hypertensive heart disease, was found to have deficiencies in the provision of activities. The resident's care plan indicated a need for in-room independent activities and regular visits to assess material needs. However, the resident reported that no activities were provided, and staff did not assist in getting them out of bed except for dialysis days. The Activities Assistant confirmed that the resident often refused in-room activities but admitted that these refusals were not documented. Additionally, the Activities Director had resigned, and records of activity participation were inaccessible. The interim Director of Nursing acknowledged that the resident had requested in-room activities and was aware of the frequent refusals, which should have been documented for proper care planning. The lack of documentation and follow-up on the resident's activity needs led to the deficiency. The resident's refusal to participate in group activities post-COVID-19 diagnosis further complicated the situation, highlighting the need for individualized activity plans and proper record-keeping.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care to Resident 60, who was dependent on staff for all ADLs due to moderate cognitive impairment and multiple medical conditions, including chronic obstructive pulmonary disease, congestive heart failure, and dementia with behaviors. Observations over several days revealed that Resident 60 was consistently left in a disheveled state, wearing the same nightgown, and in need of facial and oral care. These observations were made on four separate occasions, indicating a pattern of neglect in providing basic grooming and hygiene care as required by the facility's policy. Interviews with staff further confirmed the deficiency. On one occasion, a Certified Nursing Assistant (CNA) admitted to not assisting Resident 60 with her ADLs for the day. The Director of Nursing also acknowledged that staff are expected to provide basic grooming to residents daily, highlighting a failure to adhere to the facility's policy and the resident's care plan. This lack of care and assistance directly contradicts the facility's policy, which mandates that residents be provided with appropriate support and assistance to maintain or improve their ability to carry out ADLs.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to ensure oxygen was delivered at the correct rate following physician orders for a resident reviewed for respiratory care. Observations revealed that the resident's oxygen concentrator was set at 3.5 liters per minute, while the physician's order specified 4 liters per minute. This discrepancy was confirmed by a registered nurse who subsequently adjusted the oxygen flow to the correct rate. The facility's policy on oxygen administration requires reviewing the physician's order for oxygen delivery, which was not adhered to in this instance. Additionally, the resident's medical records indicated that oxygen was to be administered at 4 liters per minute via nasal cannula, with oxygen saturation levels to be checked every shift. Despite this, the oxygen was not delivered as ordered, and there were no respiratory assessments noted in the medical records. The facility's interim Director of Nursing confirmed that care plan meetings are conducted regularly, and oxygen tubing is changed weekly, but these protocols were not followed in this case, leading to the deficiency.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to assess and provide pain medication as prescribed to Resident 60 in a timely manner. Resident 60, who has a history of chronic obstructive pulmonary disease, congestive heart failure, major depressive disorder, muscle weakness, rheumatoid arthritis, dementia with behaviors, anxiety disorder, and chronic pain, was observed to be in pain and did not receive timely pain management. The resident's care plan included scheduled pain medications and PRN Naproxen for pain, and the resident was able to verbalize when in pain. However, during an observation, the resident expressed pain to a Registered Nurse (RN), who did not assess the pain scale and delayed administering the pain medication by nearly an hour, during which the resident was observed crying and grimacing due to pain. The facility's policy on pain management requires nursing staff to assess residents for pain and provide pain medication in a timely manner. Despite this, the staff failed to follow the protocol, as evidenced by the delay in administering pain medication to Resident 60. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the staff are required to assess and manage pain promptly, which was not adhered to in this instance. This deficiency was identified through observation, interview, and record review, highlighting a lapse in the facility's pain management practices.
Failure to Provide Dinner Meal Tray to Returning Resident
Penalty
Summary
The facility failed to provide a resident with a dinner meal tray upon their return from the hospital. The resident, who is cognitively intact with a BIMS score of 15 out of 15, returned to the facility around 4:30 PM or 5:00 PM and did not receive their dinner tray. Instead, the resident was given two sandwiches, which they stated were insufficient as they had not eaten before leaving the hospital. The resident's physician orders indicated a regular, large portion diet with regular texture and thin liquids consistency. Interviews with the Registered Dietitian and the Dietary Manager revealed that meal tickets for dining staff are printed at 3:00 PM each day. If a resident returns or is admitted after this time, nursing staff are responsible for informing the kitchen that a meal tray is needed. Both the Registered Dietitian and the Dietary Manager acknowledged that it is unacceptable for a resident to miss a meal and emphasized that nursing staff should ensure all residents receive their meals. The failure to provide the resident with a dinner tray was attributed to a lack of communication between nursing staff and the kitchen.
Latest citations in South Carolina
A resident with dementia, severe cognitive impairment, wandering behavior, and documented elopement risk eloped after staff failed to adequately respond to an exit-door alarm and did not promptly recognize the resident was missing. The resident, who required close supervision and was on 30-minute checks for wandering, was last seen ambulating in the facility before a dining room/fire exit alarm sounded; dietary staff briefly checked, saw no one, silenced the alarm, and returned to work without initiating a facility-wide missing-resident response. Later, when the resident did not appear for dinner, staff began searching and learned from a staff member driving home that someone resembling the resident was seen near a nearby store. Police, responding to a report of a suspicious person with a hospital bracelet, found the resident disoriented at a nearby intersection and arranged EMS transport to a hospital. Interviews showed that some CNAs lacked elopement training, one CNA was newly assigned to 1:1 care, and leadership acknowledged uncertainty about how long the alarm had been sounding and how the resident exited, supporting the finding of inadequate supervision and failure to prevent elopement.
A resident with traumatic brain injury, moderate cognitive impairment, wheelchair dependence, and documented wandering behaviors eloped from the facility after being able to exit through a door without an active alarm. Despite physician orders and a care plan requiring wander guard checks every shift, MAR/TAR review showed these checks were largely undocumented prior to the incident. Staff notes described frequent redirection needs, room-to-room wandering, and impulsive behavior, yet the resident was still able to leave the building and was later found in the parking lot. The State Agency determined this failure to supervise and to implement ordered wander guard monitoring constituted Immediate Jeopardy under F689 (Quality of Care).
A cognitively impaired resident with dementia and depression, who was usually independent with toileting, became involved in an altercation with a CNA while the CNA was assisting with cleaning a soiled bathroom. The resident became agitated, spit on the CNA, and struck the CNA in the face with a BM-soiled washcloth. In retaliation, the CNA held the resident’s hands and struck the resident in the face with an open hand, later describing the action as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff and law enforcement that she had put her hands on and slapped the resident. Staff assessments noted the resident was visibly upset but without visible injuries, and the resident could not recall the incident due to severe cognitive impairment. Surveyors determined this constituted non-compliance with abuse regulations and cited the facility for failure to ensure freedom from physical abuse.
A resident with severe cognitive impairment, a history of falls, and documented need for a gait belt and walker during transfers was ambulated from the bathroom by a CNA without a gait belt in place. The CNA reported holding the resident’s pants while walking, during which the resident’s feet became twisted and she fell in her room. Facility documentation showed the resident had been assessed as requiring a gait belt, but gait belt use was not included in physician orders or the care plan and was instead communicated via door name tags. The resident sustained a left hip fracture requiring surgical repair and was later readmitted for rehab and strengthening.
A resident with Alzheimer’s disease and hypertension, treated with Benazepril and enrolled in PACE, had multiple significantly elevated BP readings over two consecutive days. Facility policy required prompt physician notification for significant changes in condition, and the care plan directed staff to contact PACE for medical needs. However, there was no documentation in nursing notes that the physician or PACE was notified, and the patient liaison and weekend supervisor reported not being informed. A CNA stated she reported the elevated BP to an RN, but the RN later indicated that if no progress note existed, the notification was not documented, resulting in a failure to notify the physician of the resident’s elevated blood pressures.
A resident with epilepsy, paranoid schizophrenia, and dementia did not receive 11 ordered doses of Lacosamide 100 mg, prescribed as 1.5 tablets PO BID for seizures, because the facility failed to obtain and administer the medication and did not develop a care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR showed repeated omissions, and interviews revealed that although there was a protocol for handling missing medications—requiring nurses to call the pharmacy, notify the MD for alternatives, and check Omnicell—this process was not effectively followed or documented. The DON reported being unaware that there was no prescription for the medication, and the PCP stated she was never notified of the missed doses and that any missing medication should have been communicated to the NP and then to her by direct, immediate means.
Surveyors found that washer filters were heavily soiled with lint and debris on all observed machines, despite manufacturer instructions and a label on the equipment requiring daily cleaning. The Laundry Supervisor stated that laundry staff did not maintain the filters and that maintenance was responsible, while the Maintenance Supervisor reported the filters were typically cleaned three times per week and that no documentation was kept to verify cleaning in accordance with manufacturer guidelines.
A resident with multiple medical conditions and decreased ability to perform ADLs was found with two white tablets in a medication cup on the bedside table, which the resident identified as Imodium saved from a prior medication pass. Facility policy requires staff to remain with residents until oral medications are swallowed and prohibits leaving medications in a room without a self-administration order. Record review confirmed there was no such order for this resident. An LPN verified that medications had been left at the bedside contrary to policy, and the DON stated that nurses are not to leave medications at the bedside and must observe residents swallowing medications.
An LPN pre-poured medications for more than one resident and failed to follow required resident-identification and "five rights" checks, resulting in a resident with dementia and multiple comorbidities receiving another resident’s ordered regimen, including oxycodone 30 mg, multiple antihypertensives, an antiarrhythmic, and gabapentin, none of which were prescribed for her. After receiving the wrong medications mixed in pudding, the resident developed hypotension, bradycardia, somnolence, and hypoxia, with documented very low BP and HR, and was transferred to the hospital where she required IV fluids, naloxone, atropine, and vasopressor support and was diagnosed with drug-induced hypotension, accidental drug overdose, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. Surveyors found that this failure to adhere to the facility’s medication administration policy and to ensure residents were free from significant medication errors constituted non-compliance at F760, rising to Immediate Jeopardy.
The facility failed to report a serious medication error that led to a resident’s hospitalization to the Administrator and State Agency within the required two-hour timeframe. An LPN pre-pulled medications for more than one resident, became distracted, and administered another resident’s medications, including multiple cardiac and pain medications, to a resident with dementia, atrial fibrillation, dysphagia, and depression. The resident subsequently developed hypotension, bradycardia, and decreased respirations and was transferred to the hospital. Although the LPN notified supervisory nursing staff and the NP, the incident was not entered on the reportable incident log, the Administrator was not promptly informed, and the State Agency was not notified, in part because the ADON was unaware of the reporting requirement and the DON was on leave.
Failure to Supervise High-Risk Wanderer Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident with known cognitive impairment and wandering behaviors. The resident had dementia with severe cognitive impairment, a BIMS score of 7/15, generalized muscle weakness, unsteadiness on feet, and abnormal gait and mobility. The admission MDS and care plan identified the resident as at risk for falls and elopement, with documented wandering throughout the facility and a recent elopement. An elopement risk observation completed shortly before the incident documented that the resident did not have safe decision-making capabilities. Nursing staff reported that the resident remained ambulatory with good strength and endurance, had impaired judgment and poor safety awareness, and required close supervision due to ongoing exit-seeking behaviors. On the day of the incident, staff last observed the resident in a safe environment ambulating in the facility between approximately 5:30 PM and 5:40 PM, which was described as baseline behavior. Around this same time frame, the alarm on a dining room/fire exit door near the dietary department sounded. Dietary staff responded, visually checked the area, reported not seeing anyone, re-engaged or disarmed the alarm, and returned to the kitchen. Multiple staff later acknowledged that it was difficult to hear the alarm in the kitchen and that they were unable to determine how long the alarm had been sounding before it was noticed. The facility’s elopement policy required immediate notification of all employees and a prompt, thorough search process when a resident was considered missing, but there is no indication that a facility-wide code or missing resident procedure was initiated at the time the door alarm sounded. Subsequently, between approximately 5:50 PM and 6:05 PM, the resident’s CNA noticed the resident was not in the room to receive a dinner tray and began looking for the resident, prompting a census head count. Staff were unable to locate the resident in the building, and a search was initiated. Around 6:08 PM to 6:39 PM, an employee leaving work by car believed they saw the resident near a nearby Dollar General store and called the facility. A nurse drove to the store but did not find the resident. During this period, the local police were notified by Dollar General about a suspicious person with a hospital bracelet. Police located the resident at a nearby intersection; the police report described the resident as delirious, disoriented, and unable to provide coherent responses. EMS was requested, and the resident was transported to a hospital emergency department. The facility later confirmed that the resident had eloped from the building and was found with a wander guard still in place, and staff, including the administrator and DON, were unable to state exactly how the resident exited the building, though they believed it may have been through the dining room door whose alarm had sounded earlier. Interviews with staff revealed additional gaps related to supervision and elopement procedures. One CNA assigned to 1:1 care for the resident stated it was her first day in that role and could not confirm how long the resident had been on 1:1 care. Another CNA, who had recently completed orientation, reported not receiving any in-service training related to elopements and stated that the survey interview was the first time she heard about the resident’s exit from the building. The LPN on duty reported that the resident had been on 30-minute checks due to wandering, last saw the resident around 5:25 PM–5:30 PM, and assumed the resident was doing usual laps in the facility. The DON and administrator both acknowledged that staff could not determine how long the door alarm had been sounding before it was heard and that staff responded by looking outside, not seeing anything, and shutting off the alarm. These actions and inactions, in the context of a known high-risk, cognitively impaired, exit-seeking resident, led to a successful elopement and formed the basis of the cited deficiency under 42 CFR 483.25 for failure to keep the environment free of accident hazards and provide adequate supervision.
Removal Plan
- Evaluate resident at emergency room; confirm no injuries.
- Initiate and continue 1:1 supervision for the resident.
- Assess each exit door to validate doors are working properly.
- Update the resident’s elopement risk assessment to reflect current status.
- Update the resident’s care plan and resident profile.
- Complete an elopement drill.
- Administrator will notify the charge nurse, Director of Nursing, and Social Service designee that a resident is missing as part of drill procedure.
- Director of Nursing/designee will announce Code [NAME] to signal the elopement drill procedure.
- Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds; complete the entire search process within 30 minutes.
- If search fails to locate resident within allotted time, Administrator/designee will place a mock telephone call to appropriate community agencies, resident's legal representative, and attending physician; staff will provide mock police with physical identifying information.
- Continue the search if resident not located, including having staff search surrounding streets by car for a 2 mile radius.
- When the volunteer resident is located, the charge nurse will complete a head-to-toe assessment.
- Social Services designee will assess the resident for emotional distress.
- Director of Nursing will notify appropriate community agencies, attending physician, and resident's legal representative.
- Facility Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences.
- When missing resident is found, make an announcement: Code [NAME] all clear.
- Update elopement risk assessments for all residents.
- Place residents identified as elopement risk in the elopement binder and update their care plans and profiles.
- Reeducate facility staff on the elopement policy and Abuse, Neglect & Misappropriation policy.
- Provide education to any staff not receiving this education prior to their next scheduled shift.
- Review new admission elopement risk assessments in Clinical Morning Meeting to validate accuracy and interventions if indicated.
- Review quarterly elopement risk assessments to validate accuracy and interventions if indicated.
- Maintenance Director/designee will inspect facility exit doors to validate doors are functioning properly.
- Administrator will round with the Maintenance Director validating doors are functioning properly.
- Hold an Ad Hoc QACPI.
- Notify the Medical Director of the incident and plan.
- Present results of audits in the QAPI Committee meeting for review and recommendations.
Failure to Monitor Wander Guard and Supervise Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and prevent a successful elopement for one resident identified as at risk for wandering and elopement. The resident was admitted with diagnoses including traumatic subdural hemorrhage, muscle weakness, difficulty in walking, and need for assistance with personal care. An admission MDS showed a BIMS score of 9/15, indicating moderate cognitive impairment, and documented that the resident used a wheelchair and required substantial assistance for most ADLs. The facility’s own policy defined wandering and elopement, required staff training on elopement prevention, and called for interventions and care plan documentation for residents at risk of elopement. Physician orders were in place directing staff to check the resident’s wander guard for effectiveness and function every shift beginning shortly after admission. However, review of the MAR/TAR for the period from admission through the date of elopement showed that this order was not consistently documented as completed. For the period 01/30/26–02/19/26, there was an order to check the wander guard every shift, but it was only signed once on the date of the elopement for the first shift. There was no documentation on the MAR/TAR for January related to checking the wander guard, despite the order being in effect. The resident’s care plan, initiated on admission and revised on 02/19/26, identified behavioral symptoms of wandering and elopement related to impaired cognition and impulsivity, and included an intervention to equip the resident with a wander guard upon admission for 48 hours and to check the device’s proper functioning every shift, but the documented implementation of these checks was lacking. In the days leading up to the elopement, progress notes documented that the resident needed frequent redirection due to wandering in and out of other residents’ rooms, and that staff discussed with the resident’s representative the possibility of obtaining a sitter because of these behaviors. Another note described the resident being found seated on a fall mat after getting out of bed to remove pictures from the wall and pack his bag, indicating ongoing impulsive and wandering behavior. On the night of the elopement, a CNA reported that the resident had been described as hard to redirect and constantly pacing the unit in his wheelchair. Later that night, the resident was found wandering in the parking lot and brought back inside by a CNA; the nurse documented that the door alarm was not going off at the time the resident was found outside. The resident’s representative later stated that he had been informed that the front door was not working properly and that the resident had a wander guard device that should have locked the door when he left, but the door did not function correctly, allowing the resident to exit the building. Based on these findings, surveyors determined that the facility failed to provide adequate supervision and accident prevention, resulting in a successful elopement and an Immediate Jeopardy determination at F689. The State Agency determined that the facility’s non-compliance with federal health and safety regulations caused or was likely to cause serious injury, harm, impairment, or death, and identified the Immediate Jeopardy as related to 42 CFR 483.25, Quality of Care. The Immediate Jeopardy was determined to have existed as of the date of the elopement. The survey findings emphasized the lack of documented adherence to physician orders and care plan interventions for checking the wander guard device, the presence of documented wandering and impulsive behaviors, and the fact that the resident was able to leave the building without triggering a door alarm. These combined actions and inactions led to the conclusion that the facility did not ensure the environment was free from accident hazards and did not provide adequate supervision to prevent the resident’s elopement.
Removal Plan
- Resident was immediately located and safely returned to the facility.
- Full nursing assessment completed by licensed nurse; no injuries noted.
- Physician/Medical Director and responsible party notified by administrator.
- Resident placed on increased monitoring immediately.
- Wandering/elopement risk reassessed.
- Care plan updated to include enhanced interventions.
- Wander guard applied and verified functioning.
- Staff education initiated by administrator.
- Incident reported per facility policy and state requirements.
- Facility conducted a 100% audit of all residents for elopement risk.
- Verified wander guard placement and function for all residents.
- Verified accuracy of assessments and care plans for all residents.
- Updated care plans to include individualized interventions such as secured unit placement/discharge plan and structured activities to reduce wandering.
- Conducted environmental safety checks.
- All exit doors secured and alarmed and verified by maintenance department weekly.
- Wander guard system tested by maintenance department weekly with a log.
- All staff education completed by DON/Administrator on policy/protocol for wandering and elopement and immediate response procedures if a resident is missing.
- Results reviewed in QWAPI meetings monthly for 3 months, with corrective actions implemented as needed.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident from physical abuse by a CNA. The facility’s abuse policy defines physical abuse as including hitting, slapping, and controlling behavior through corporal punishment. The resident involved was admitted with major depressive disorder and dementia with agitation, and a recent MDS showed a BIMS score of 7/15, indicating severe cognitive impairment. The resident was generally independent with toileting and transfers. On the day of the incident, the resident was on a locked dementia unit and had experienced bowel incontinence, leaving the bathroom soiled. A CNA entered the resident’s room to assist with cleaning the bathroom. During this interaction, the resident became agitated and combative, reportedly spitting on the CNA and striking the CNA in the face with a wet washcloth containing bowel movement. The CNA later reported that she responded by holding the resident’s hands above her head and then making contact with the resident’s face with an open hand, described as a slap or “smudging” the resident’s face. The CNA admitted to multiple staff, including the charge nurse, DON, Administrator, and Social Services, that she had put her hands on the resident and struck the resident in the face with an open hand in retaliation for the resident’s actions. A police report documented that the CNA admitted to assaulting the resident with an open-hand slap during a physical altercation. Staff who assessed the resident after the incident noted that the resident appeared visibly upset but had no visible injuries, and the resident was unable to recall the specific events due to severe cognitive impairment. The State Agency determined that the facility’s non-compliance with abuse regulations caused or was likely to cause serious harm and cited the facility under 42 CFR 483.12 for failure to ensure the resident was free from physical abuse.
Removal Plan
- Removed CNA3 from the resident care area after the incident.
- Interviewed CNA3 regarding the incident.
- Terminated CNA3 by the Administrator and DON.
- Notified law enforcement of the incident.
- Submitted a report to the Regional Ombudsman.
- Completed a nursing assessment and body audit of R1; no injuries found.
- Notified R1's family/responsible party of the incident.
- Monitored residents for psychosocial distress or changes by nursing staff and Social Services.
- Provided 1:1 re-education for staff working in skilled nursing on abuse and appropriate response/intervention and workplace fatigue.
- Conducted an investigation and determined there was no physical evidence of abuse.
- Social worker interviewed all residents on Unit 3 regarding abuse, whether any abuse had been witnessed/experienced, and whether residents felt safe.
- Social worker interviewed residents on other skilled units regarding abuse and whether residents felt safe.
- Arranged for MD and PA to evaluate R1; MD issued new medication orders and PA checked on the resident.
- Obtained family consent for a psychiatric evaluation.
- Social worker contacted the family and obtained updates; family visited and reported no changes in mood/behavior/psychosocial status.
- Social worker checked in on R1 and monitored for changes.
- Initiated in-house education for all staff working in Skilled Nursing on types/definitions of abuse, dementia with abuse prevention, de-escalation of behaviors, and how to appropriately avoid these situations.
- Re-educated staff on who the Abuse Coordinator is and how to notify the Abuse Coordinator of concerns.
- Reviewed the abuse policy with staff.
- Obtained statements from all staff who work in Skilled Nursing.
- Continued education ongoing.
- Nursing management (DON, ADON, Unit Managers) to conduct rounding and audits for signs of abuse.
- Held QAPI and updated it regarding this issue.
Failure to Use Required Gait Belt During Ambulation Resulting in Hip Fracture
Penalty
Summary
The facility failed to ensure a resident was free from accident hazards and received adequate supervision during ambulation, resulting in a fall and left hip fracture. The facility’s Fall Management Program policy included staff education and interventions to prevent unsafe transfers and ambulation. The resident had severe cognitive impairment, as evidenced by a BIMS score of 3/15, and used a walker and wheelchair. A Safe Resident Handling Data Collection form documented that a gait belt and walker were required for transfers with staff and that the resident continued to require use of a gait belt. The resident’s care plan included assistance with transfers and ambulation and provision of adaptive equipment, but there was no physician order for a gait belt, and gait belt use was not listed on the care plan. Instead, the Administrator stated that transfer methods, including gait belt use, were communicated via name tags on residents’ doors and that the resident had a history of tripping over her own feet and falling. On the day of the incident, the resident was being assisted by a CNA from the bathroom when the resident’s feet became twisted and she fell to the floor. The CNA reported she was holding the resident’s pants while walking her from the bathroom and acknowledged that the fall was her fault. Documentation indicated the resident fell in her room while being transferred/ambulated from the bathroom with the CNA present, wearing shoes at the time. The Administrator confirmed that the resident had been assessed for gait belt use and that the resident did not have a gait belt on when she fell. The Administrator stated that, in situations where a resident is already in motion without proper equipment, staff should hold the resident and call for help rather than continue ambulation. The resident sustained a subcapital femoral neck fracture of the left hip, required surgical repair at a hospital, and was later readmitted to the facility for rehabilitation and strengthening, with documentation noting she had been confined to a wheelchair prior to the fall and was unlikely to progress beyond her previous level of activity.
Failure to Notify Physician of Resident’s Elevated Blood Pressures
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of significantly elevated blood pressures as required by facility policy. The facility’s policy on Change in a Resident’s Condition or Status, revised February 2021, states that the nurse will promptly notify the attending or on-call physician when there is a significant change in the resident’s physical condition, defined as a major decline or improvement that will not normally resolve without intervention. The resident was admitted with diagnoses including Alzheimer’s disease, essential hypertension, and hypothyroidism, and had an active order for Benazepril 5 mg daily for hypertension with instructions to hold the medication if systolic blood pressure (SBP) was less than 110. The admission MDS showed the resident was unable to complete the BIMS interview and had an active diagnosis of hypertension. Blood pressure records showed multiple elevated readings, including 172/102 and 172/101 on one day and 171/119 on the following day. Review of the nurse’s notes revealed no documentation that the physician or PACE program was notified of these elevated blood pressures. The care plan indicated the resident was a PACE participant and directed staff to contact PACE for any medical needs. During interviews, the UM stated all medication orders came from PACE, and the DON acknowledged that 171/119 was an elevated blood pressure and that a call should have been made to the on-call PACE medical director, with family also to be notified of the change in condition. The patient liaison and weekend supervisor both reported not being informed of the elevated blood pressures, and CNA staff reported notifying an RN of the elevated readings but was unsure what occurred afterward. The RN stated she did not recall the patient but indicated that if there was no progress note, the notification would not have been documented anywhere else.
Failure to Obtain and Administer Ordered Seizure Medication
Penalty
Summary
The facility failed to obtain and administer Lacosamide, an ordered seizure medication, for one resident, resulting in 11 missed doses over the period from 1/7 to 1/13. The resident was admitted with diagnoses including epilepsy, paranoid schizophrenia, and dementia. Review of the care plan showed no care plan addressing epilepsy, seizure risk, or seizure medications. Review of the MAR for 1/7/26 through 1/14/26 showed that the resident did not receive Lacosamide 100 mg, ordered as 1.5 tablets by mouth twice daily for seizures, for a total of 11 missed doses. The facility’s policy on Adverse Consequences and Medication Errors defined a medication error to include omissions when a drug is ordered but not administered. During interviews, an LPN stated that if a progress note about Lacosamide not being given was scratched out, it meant the medication was administered, and that when waiting for a medication, the nurse keeps a running list and calls the pharmacy for status updates. The Staff Development Coordinator reported that the protocol for missing medications requires nurses to call the pharmacy and document the call, notify the MD for alternatives, and check the Omnicell if the medication is not a narcotic. The DON stated that on admission, floor nurses should send all prescriptions to the pharmacy and, if a prescription is missing, contact onsite/on-call providers to obtain one so the pharmacy can send the medication stat, and reported being unaware that there was no prescription for Lacosamide. The resident’s PCP stated she had no memory of being notified about any missed Lacosamide doses and explained that the NP should be notified first and work with the pharmacy, and if issues persist, the PCP should be contacted; she also stated that missing medication should be communicated immediately by direct means, not by a note left in a book.
Failure to Maintain Washer Filters per Manufacturer Instructions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the maintenance of laundry equipment. Review of the Alliance Laundry Systems washer manufacturer guidelines showed that, as part of end-of-day maintenance, the AC invert drive filter was to be cleaned by removing the external plastic cover, taking out the foam filter, and washing it with warm water and allowing it to air dry, or by vacuuming the filter. During an observation of the laundry area, the filter located on the front of the washing machine was found to be heavily soiled with lint and debris, despite a metal manufacturer label directly beneath the filter stating, "Clean Daily." Three of three washing machines observed had this issue. In an interview conducted at the time of the observation, the Laundry Supervisor acknowledged the condition of the filter and stated that laundry personnel did not maintain the filter, indicating that maintenance staff were responsible for cleaning it. In a subsequent interview, the Maintenance Supervisor reported that maintenance staff usually cleaned the filter about three times a week on Monday, Wednesday, and Friday, rather than daily as directed by the manufacturer. The Maintenance Supervisor also stated there was no log or record maintained to verify that the filter was cleaned as required.
Medications Left at Bedside Without Self-Administration Order
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when medications were left at the bedside for one resident. The facility’s “Oral Medication Administration Procedure” policy states that staff must administer oral medications in an organized and safe manner, remain with the resident while the medication is swallowed, and never leave medication in a resident’s room without an order for self-administration. Review of the resident’s orders showed there was no order for self-administration of medication. The resident involved had diagnoses including post hemorrhagic anemia, gastrointestinal hemorrhage, irritable bowel syndrome, and osteoarthritis, and had a BIMS score of 15/15, indicating no cognitive impairment. The baseline care plan documented decreased ability to perform ADLs/self-care related to debility/generalized weakness. During observation, two white tablets were found in a medication cup on the resident’s bedside table. An LPN confirmed the medications should not have been left in the room and that the resident did not have an order to self-administer. The resident stated that a nurse had brought the medications the previous night and that she was saving them to use when needed, identifying them as Imodium. The DON stated that nurses are not to leave medications at the bedside and should remain with the resident to ensure medications are swallowed safely, and that anyone could take medications left at the bedside.
Significant Medication Error When Wrong Resident Received Another Resident’s Medications
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an LPN administered another resident's medications. Facility policy required that medications be administered safely and as prescribed, including verifying the resident's identity before administration using methods such as checking an identification band, reviewing a photograph on the medical record, and, if necessary, confirming identity with other staff. The policy also required the person administering medications to check the label three times to verify the right resident, medication, dosage, time, and route, and prohibited administering medications ordered for one resident to another. Despite these requirements, the LPN pre-poured medications for more than one resident at a time and did not correctly verify the resident's identity before administration. The resident who received the wrong medications, identified as R2, had been admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. Another resident, identified as R3, had diagnoses including heart failure, high blood pressure, chronic pain syndrome, and lumbar spondylosis, and had active orders for multiple medications: oxycodone 30 mg three times daily, amlodipine 5 mg (two tablets once daily), losartan 50 mg twice daily, dofetilide 250 mcg twice daily, gabapentin 600 mg four times daily, and metoprolol 50 mg once daily. R2 did not have physician orders for these medications. On the morning of the incident, the LPN labeled a medication cup with a resident's name, poured medications into the cup, mixed whole pills in pudding, and administered them to R2 in her room. The LPN later discovered that R2's medication cup was still on the cart and realized that the medications given to R2 were actually those prescribed for R3. Following the administration error, staff documented that R2 had received oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide 250 mcg (also documented once as 520 mcg), gabapentin 600 mg, and metoprolol 50 mg, none of which were ordered for her. Progress notes and vital sign records showed that R2 subsequently experienced low blood pressure and slow heart rate, with multiple blood pressure readings in the 70s and 80s systolic and 40s diastolic, and heart rates in the 40s and 50s. A nurse practitioner assessed R2 shortly after the error and initially noted no acute distress, but within an hour R2 became symptomatic. Later documentation indicated that R2 was transferred to the hospital, where she was evaluated for somnolence, hypotension, bradycardia, and hypoxia after receiving the incorrect medications. Hospital records described that she required interventions including IV fluids, naloxone, atropine, and vasoactive medications due to persistent hypotension over several days, and she was diagnosed with hypotension due to drugs, drug overdose (accidental or unintentional), confusion caused by a drug, bradycardia, respiratory insufficiency, sepsis with acute hypoxic respiratory failure, and pneumonia. The state survey agency determined that the facility's non-compliance with pharmacy services requirements caused or was likely to cause serious injury, harm, impairment, or death, and cited the facility at F760.
Removal Plan
- The Administrator notified the Medical Director of the Immediate Jeopardy.
- R2 was assessed by the Nurse Practitioner, and new orders were written for vital signs every 30 minutes and Midodrine stat.
- R2 was sent to the emergency department for a higher level of care.
- The Assistant Director of Nursing began the investigation into the medication error.
- The Assistant Director of Nursing counseled LPN1 related to the medication error and failure to follow the five rights of medication pass, including prepulling medication that resulted in the medication error; the licensed nurse was placed on a process improvement plan.
- The Assistant Director of Nursing provided 1:1 education with LPN1 related to types of medication errors, causes, and prevention.
- The Assistant Director of Nursing began a medication pass in-service related to the 5 rights of medication administration.
- The Assistant Director of Nursing or designee began education with the licensed nurses on the 5 rights of medication pass and medication administration.
- The Assistant Director of Nursing or designee began education on the medication administration policy to include how to verify the medications are correct for all licensed nurses on or before their next scheduled shift.
- The Assistant Director of Nursing or designee began competency checks on medication pass on all licensed nurses.
- The Administrator, the Director of Nursing, and the Assistant Director were re-educated on Medication Pass, including medication errors, by the Regional Assistant Director of Clinical Services.
- The Director of Nursing completed a review of hospitalizations to determine if any were related to medication error.
- The Director of Nursing completed a medication error review to ensure proper documentation, appropriate corrective action, and reporting compliance.
- Nurse management will randomly select each nurse daily to observe medication passes for 7 days, then weekly for 4 weeks, then monthly for 2 months.
- The nurse involved in the deficiency will complete medication pass competency daily for 7 days, weekly for 4 weeks, monthly for 2 months, and quarterly for 2.
Failure to Report Serious Medication Error Resulting in Resident Hospitalization
Penalty
Summary
The facility failed to timely report a significant medication error that resulted in serious bodily injury to the Administrator and the State Agency within two hours, as required by its own abuse, neglect, exploitation, and misappropriation reporting policy. The policy, last revised in September 2022, states that suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the Administrator and appropriate authorities, defining "immediately" as within two hours for allegations involving abuse or resulting in serious bodily injury. Despite this, the medication error involving Resident 2, which led to hospitalization, was not entered on the facility’s reportable incident log and was not reported to the State Agency or Administrator as required. Resident 2 was admitted with diagnoses including cognitive communication deficit, dementia with mild anxiety, atrial fibrillation, dysphagia, and major depressive disorder. On the morning of 12/04/25, LPN1 pre-pulled medications for more than one resident at a time and prepared medications for Resident 2 and Resident 3. When Resident 3 requested pain medication, LPN1 retrieved oxycodone for Resident 3 but then became distracted and administered Resident 3’s medications to Resident 2 instead. Witness statements from the Unit Manager and ADON documented that Resident 2 received multiple medications not prescribed for them, including oxycodone 30 mg, amlodipine 5 mg, losartan 50 mg, dofetilide, gabapentin 600 mg, and metoprolol 50 mg. Progress notes show that Resident 2’s blood pressure remained low despite ordered midodrine and fluids, with documented hypotension, bradycardia, and decreased respirations, and the resident was ultimately transferred to the hospital for further evaluation. Following the error, LPN1 reported the incident to her supervisor, and the ADON and NP were notified; however, the Administrator and State Agency were not notified as required by policy. The DON, who was on maternity leave at the time, later stated that the incident should have been reported to the State Agency but confirmed that no report was submitted and that the ADON was unaware the incident needed to be reported. The ADON stated she was unsure if the Administrator had been notified and acknowledged she did not know she was required to report the incident to the State Agency. The Facility Administrator reported that he only became aware of the medication error recently, after speaking with another resident, and confirmed that no report had been sent to the State Agency and that he had not been informed of the incident when it occurred.
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