Ambrosio Guillen Texas State Veterans Home
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 9650 Kenworthy St, El Paso, Texas 79924
- CMS Provider Number
- 676060
- Inspections on file
- 35
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Ambrosio Guillen Texas State Veterans Home during CMS and state inspections, most recent first.
Nursing staff performed blood glucose checks and insulin injections for four cognitively impaired, diabetic residents in a TV/common room, in full view and hearing range of more than 15 other residents. These residents, who had documented dementia, communication impairments, and daily insulin needs, received treatments that exposed their skin and disclosed their glucose readings, insulin type, and dosage in a public area. Facility leadership, including the Supervisor RN, Unit Manager, ADON, and Administrator, acknowledged that such care should occur in residents’ rooms to maintain privacy, dignity, and confidentiality, and that the observed practice conflicted with resident rights and facility policy.
An LVN performed wound care on a resident with a Stage 4 sacral pressure injury while wearing an unsecured gown, failed to perform hand hygiene or change gloves after removing soiled dressings and cleaning the wound, removed and discarded the gown mid‑procedure, and continued care without a gown until stopped by a surveyor. Separately, an RN conducted serial blood glucose checks and insulin injections for four residents with diabetes and cognitive impairment without sanitizing hands between glucose testing and insulin preparation, after injections, or between residents, and sometimes touched the medication cart and room door handles without prior hand hygiene. In interviews, the LVN and RN acknowledged they did not follow expected infection control practices, while supervisory staff and leadership described that facility policy and standard practice required multiple hand hygiene opportunities and appropriate PPE use during wound care and glucose monitoring with insulin administration.
A resident with diabetes and chronic left foot wounds was diagnosed with osteomyelitis by an outside podiatrist, with imaging confirming calcaneal involvement and possible 5th toe osteomyelitis. The podiatrist’s note documented the diagnosis and a plan to consult infectious disease, but facility records contained no timely nursing progress note showing that the NP/MD was informed when this diagnosis was first identified. Staff interviews confirmed that the receiving nurse was responsible for reviewing outside notes and immediately notifying the NP/MD of new diagnoses, yet the NP reported learning of the osteomyelitis from the resident’s family rather than from facility staff. The DON stated she believed immediate notification was unnecessary because the condition was described as stable and there were no new orders, despite facility policy requiring physician notification for new conditions and skin issues.
A resident with diabetes, open foot wounds, and hospital-confirmed left calcaneal osteomyelitis received IV therapy and related interventions per the care plan, but the discharge MDS did not include osteomyelitis as an active diagnosis. The MDS LVN reported relying on floor nurses to update diagnoses and reviewing MDS assessments only quarterly, viewing missing diagnoses primarily as a reimbursement issue and noting no in-service training on accurate MDS completion. The Administrator focused mainly on BIMS scores, was unsure that diagnoses must be included on the MDS, acknowledged that omissions fail to show the full clinical picture, and could not recall the last in-service, despite a facility policy requiring comprehensive assessments per RAI criteria when significant changes occur.
A resident with diabetes, hyperglycemia, and left foot wounds had MRI-confirmed calcaneal and possible 5th toe osteomyelitis and was seen by a podiatrist, whose note indicated osteomyelitis and a plan to consult infectious disease. Facility progress notes did not document that the NP/MD was notified of this new or confirmed diagnosis following the outside appointment, despite staff interviews and facility expectations indicating nurses must review outside provider notes, immediately notify the NP/MD of new diagnoses, and record this in the medical record. The DON stated she believed immediate notification was unnecessary because the condition was described as stable and there were no new orders, while the Administrator stated that immediate notification and documentation were required. This lack of documentation of NP/MD notification regarding the osteomyelitis diagnosis led to the cited deficiency in maintaining a complete and accurate medical record.
A resident with a history of behavioral and medical issues alleged that an LVN squeezed her hand, resulting in bruising. Staff documented the incident and notified supervisors, but the facility did not report the abuse allegation to the State Survey Agency within the required timeframe, citing the resident's combative behavior as an alternative explanation for the injuries. The facility's policies for immediate reporting of abuse allegations were not followed.
The facility did not complete required annual employee misconduct registry and nurse aide registry screenings for two CNAs, as mandated by its own policies. This lapse was confirmed through record reviews and staff interviews, revealing that annual screenings were missing from the employee files, which could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.
Two residents experienced deficiencies in accident prevention and supervision when one was found on the floor after a fall due to an inaccessible call light and missing assist bars, while another lost independence in bed mobility after bed rails were removed and no timely PT/OT evaluation was completed. Staff interviews confirmed delays in therapy assessments and inconsistent implementation of fall prevention policies.
A registered nurse delegated a blood glucose check to a CNA, contrary to facility policy, and later administered insulin based on the result. In a separate incident, the same nurse gave an insulin injection to another resident through clothing without cleaning the site, also violating proper procedure. The facility lacked a skills checklist for insulin administration and did not maintain written documentation of staff re-education or investigation related to these incidents.
A resident with dementia and type 2 diabetes did not receive insulin as ordered when an LVN failed to check blood glucose before dinner and did not administer sliding scale insulin. On another occasion, rapid-acting insulin was given well before the resident received a meal, and no snack was provided within the recommended timeframe. These actions resulted in significant medication errors due to noncompliance with physician orders and manufacturer specifications.
A resident with intact cognition reported his wallet, containing identification documents, a Social Security card, a checkbook, and cash, as missing. Despite internal investigation and searches by staff, the wallet was not found, and the incident was not reported to the State Survey Agency as required by facility policy. The administrator determined the situation did not meet the threshold for misappropriation due to the lack of a clearly identified perpetrator, even though the policy required reporting all such allegations.
The facility failed to serve meals simultaneously to residents in the memory care unit, causing some to wait up to 30 minutes while their tablemates ate. This affected 7 out of 15 residents reviewed for residents' rights. Interviews revealed that the responsibility for ensuring simultaneous meal service lies with the nursing and kitchen staff, who failed to coordinate effectively.
The facility failed to ensure residents were aware of the grievance process, as five residents reported not knowing how to file a grievance or who to contact. Interviews with staff revealed inconsistencies in communicating the grievance process, and the facility's policy on Resident Rights was not effectively conveyed to residents.
The facility failed to post required oxygen signs outside the rooms of two residents using oxygen therapy, as observed by surveyors. This deficiency was confirmed by staff interviews, which highlighted the potential risks of unchecked oxygen levels and fire hazards. The facility's policy mandates such signage to ensure safety and proper monitoring.
The facility failed to ensure proper pharmaceutical services and record-keeping, including not signing controlled drug records and temperature logs. A resident's medication count was inaccurate due to a staff member not updating the control drug record after administering Tramadol. Additionally, the temperature log for vaccines/medications was not signed, potentially risking therapeutic responses and increasing drug diversion risks.
The facility failed to maintain clean medication and treatment carts, with liquid medication bottles found with dried drippings, posing a risk of cross-contamination. LVNs acknowledged their training to keep bottles clean, but observations revealed otherwise. The facility's policy lacked specific instructions on maintaining bottle cleanliness.
The facility failed to serve meals at the required temperature during a lunch service, with pureed, regular, and mechanical soft meals, including fried zucchini and Albondiga soup, served below 135°F. The CDM Interim acknowledged the oversight and the facility's policy requiring hot foods to be served at 135°F or higher, noting the potential risks of foodborne illnesses.
A resident with multiple health conditions, including muscle weakness and coronary artery disease, was found with her call light tangled and on the floor, making it inaccessible. Despite staff training and facility policy requiring call lights to be within reach, the resident confirmed she could not reach it and would have to wait for staff to pass by for help. Interviews with staff, including CNAs, an RN, and the DON, acknowledged the policy but it was not followed, posing a risk of unmet needs.
The facility failed to document behavioral incidents for two residents in their MAR/TAR, despite these incidents being tracked for irritability, aggression, and delusional disorders. The DON acknowledged the importance of accurate documentation for care planning, as per facility policy.
A resident with a catheter was found with the drainage bag on the floor, contrary to the facility's care plan and catheter care policy. Staff interviews revealed that the bag should have been attached to the bedframe to prevent infection. The facility's policy emphasized proper technique to prevent infections, which was not followed.
A resident receiving oxygen therapy did not have the required 'Oxygen in Use' sign posted outside their room, as observed during a survey. The resident had a history of respiratory issues and was on oxygen therapy per physician's orders. The ADON acknowledged the oversight, which was contrary to the facility's policy, although the risk was deemed minimal due to the smoke-free environment.
A facility failed to document a physician's order for PRN oxygen for a resident with respiratory issues. The resident's oxygen levels dropped, and a nurse administered oxygen but did not enter the order into the system. The DON confirmed the oversight, noting the nurse was busy stabilizing the resident. Despite the documentation lapse, the resident received continuous oxygen without negative outcomes.
The facility failed to ensure accurate MDS assessments for two residents, one with a g-tube and another with behavioral issues. These inaccuracies were confirmed by the Unit Manager and MDS Nurse, potentially affecting the residents' care and management.
The facility failed to document and implement care interventions for a resident who repeatedly pulled on a drainage tube, despite staff being aware of the behavior. The behavior was not included in the care plan, leading to multiple incidents requiring medical intervention.
The facility failed to implement their abuse prevention policies by not immediately suspending a CNA after a report of suspected roughness with a resident. The resident, who had severe cognitive impairment and behavioral symptoms, was reportedly grabbed strongly by the CNA. Despite the report, the CNA was allowed to finish her shift, and the investigation was deemed unsubstantiated due to inconsistencies in statements and lack of observed distress in the resident.
Failure to Protect Resident Privacy and Dignity During Glucose Checks and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain privacy, dignity, and confidentiality when performing blood glucose checks and administering insulin to four residents. On a specified date, RN A conducted glucose testing and insulin injections for four male residents in a TV room/common area rather than in a private setting. More than 15 other residents were in close proximity during these procedures, allowing others to see and potentially overhear the residents’ glucose readings, insulin type, and dosage. This occurred despite facility policy stating that residents have a right to personal privacy and confidentiality of their personal and medical records, including during medical treatment. The four residents involved all had diabetes mellitus and varying degrees of cognitive impairment as documented in their MDS assessments and medical records. One resident had a BIMS score of 3 and diagnoses of Alzheimer’s dementia and type 2 diabetes, with a care plan focus on disorientation from dementia and interventions to provide choices and assist with decision making. Another resident had a BIMS score of 6, diagnoses of type 2 diabetes, dementia, and bipolar disorder, and a care plan focus on impaired communication with interventions to allow adequate response time and evaluate comprehension. A third resident had a BIMS score of 4, required daily insulin injections, and had a care plan for diabetes management including monitoring for hypo/hyperglycemia, rotating injection sites, and monitoring food intake. The fourth resident had a BIMS score of 11, required daily insulin, and had care plan interventions addressing cognition, including asking simple questions, not rushing, and explaining procedures, along with diagnoses of hearing loss, type 2 diabetes, and dementia. Interviews with facility leadership confirmed that the observed practice of performing glucose checks and insulin injections in a common area was contrary to expectations and resident rights. The Supervisor RN stated that glucose checks should be done in residents’ rooms to uphold dignity and prevent others from overhearing blood sugar levels, insulin brand, and dosage, and that residents could feel embarrassed if care was provided in the open. The Unit Manager stated that blood sugar readings and insulin injections are treatments that must be completed in residents’ rooms to protect privacy and that all patient-related care should occur in residents’ rooms, including for those on a memory unit. The ADON stated that residents needed to be in their rooms for glucose readings and insulin injections because skin would be exposed and that providing such care in open areas created dignity and HIPAA concerns by disclosing glucose readings, diagnoses, dosages, and insulin types. The Administrator acknowledged that providing treatment in open areas was a privacy concern and that residents’ diagnoses, medications, glucose levels, vitals, and exposed stomachs could be seen by others, conflicting with the facility’s stated practice of providing privacy when residents receive care.
Failure to Follow Hand Hygiene and PPE Protocols During Wound Care and Insulin Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement an effective infection prevention and control program, specifically related to hand hygiene and PPE use during wound care and blood glucose monitoring with insulin administration. During wound care for a resident with a sacral pressure injury, an LVN donned a PPE gown without securing the back or neck ties, disposed of the resident’s soiled wound dressing, and continued to clean the wound without performing hand hygiene or changing gloves. The LVN then removed and discarded the gown because it was getting in the way and continued cleaning the wound without a gown. He began to open new dressings to apply to the wound and only performed hand hygiene and changed gloves after being stopped and questioned by the state surveyor. He completed the remainder of the wound care without wearing a PPE gown. The resident receiving this wound care had a documented Stage 4 pressure injury to the sacrum, with orders for daily alginate calcium primary dressing and gauze island secondary dressing, and a care plan directing staff to administer treatments as ordered and monitor for changes in skin status. The LVN later stated he forgot to wash his hands and change gloves after disposing of the dirty dressing and cleaning the wound, and acknowledged he was expected to perform hand hygiene before applying the new dressing. He reported he did not typically provide wound care because the facility had a designated wound care nurse, and that he removed the gown because it was too small and not secured, noting that larger gowns previously provided had run out and that he was supposed to notify the nurse supervisor when PPE supplies were low. The DON stated staff were to don gown and gloves at minimum for wound care, that it was not appropriate to remove the gown during the procedure without reapplying it, and that staff were expected to perform hand hygiene before applying PPE, before beginning wound care, when changing gloves during wound care, and before applying the new dressing. Additional deficiencies were observed in hand hygiene practices during glucose monitoring and insulin administration for four residents with diabetes and varying degrees of cognitive impairment. An RN performed blood glucose checks and insulin injections for multiple residents without sanitizing her hands between glucose measuring and filling the insulin syringe, and in some instances did not sanitize after administering insulin, disposing of sharps, and removing gloves before touching the medication cart and a resident’s door handle. She also proceeded from one resident to another without practicing hand hygiene between residents. In interviews, the RN acknowledged she should sanitize before and after every glove application, admitted she did not adhere to that standard, and attributed her lapses in part to not having hand sanitizer readily accessible on her cart. Other nursing staff, supervisors, the unit manager, ADON, and the DON described the expected procedure for glucose monitoring and insulin administration, consistently stating that there should be multiple (3–4) hand hygiene opportunities during the process, including before and after glove use and between residents, and that staff were responsible for following the facility’s hand hygiene and infection control policies. Facility policies on hand hygiene and infection prevention and control required staff to perform hand hygiene per established procedures and to use PPE according to facility guidelines when providing resident care.
Failure to Immediately Notify NP/MD of New Osteomyelitis Diagnosis After Outside Appointment
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify and consult with a resident’s physician or NP/MD when there was a significant change in the resident’s condition and diagnosis. The resident was an older male with diabetes mellitus with hyperglycemia and a history of open wounds on the left foot and great toe. He had been referred to a podiatrist and then to a local hospital due to concern for osteomyelitis in the left foot, with MRI imaging consistent with left calcaneal osteomyelitis and possible left 5th toe osteomyelitis. Despite this new diagnosis, the facility’s records did not show that the NP/MD was promptly informed of the osteomyelitis. Record review showed a podiatrist progress note indicating erosion of the left 5th toe consistent with osteomyelitis and a plan to consult infectious disease, but there was no corresponding nursing progress note documenting notification to the NP/MD of this new diagnosis. A progress note dated two days later documented that the resident was sent to the hospital for further evaluation regarding osteomyelitis, but the facility’s documentation did not reflect that the NP/MD had been notified when the diagnosis was first identified. The resident’s care plan included IV therapy related to osteomyelitis, with interventions such as administering IV fluids per order, monitoring for infection, and notifying the physician of signs and symptoms of infection or complications, but the initial diagnostic information from the podiatrist visit was not promptly relayed. In interviews, nursing staff and leadership described that the receiving nurse was responsible for reviewing outside provider notes and immediately notifying the NP/MD of any new orders or diagnoses, and then documenting a progress note. LVN staff acknowledged that failure to notify the NP/MD could cause a delay in care and miscommunication, and one LVN stated he only learned of the osteomyelitis diagnosis from the resident’s POA. The NP reported she was not notified by facility nurses about the osteomyelitis diagnosis and instead learned of it from a family member. The DON stated that because the podiatrist’s note contained no new orders and described the condition as stable with a referral to infectious disease, she believed immediate notification of the NP was not necessary and that next-day notification would be acceptable. The facility’s written policy on change in resident condition required licensed nurses to notify the attending physician or designee and resident representative in situations requiring a change in medication or treatment regimen, including new conditions and skin issues, but the osteomyelitis diagnosis was not immediately communicated to the NP/MD as required.
Failure to Accurately Code Osteomyelitis Diagnosis on Discharge MDS
Penalty
Summary
The facility failed to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s active diagnosis of osteomyelitis. The resident, an adult male admitted with a history including an open wound of the foot, open wound of the left great toe, and diabetes mellitus with hyperglycemia, was referred to the hospital due to concern for osteomyelitis of the left foot. Hospital records, including MRI imaging, documented left calcaneal osteomyelitis and possible left 5th toe osteomyelitis, and the resident was admitted for management of a urinary tract infection and a left open wound concerning for osteomyelitis, with a plan for antibiotic therapy prior to return to the facility. Despite this, the resident’s discharge MDS did not include osteomyelitis as a diagnosis, even though the resident’s care plan identified a need for IV therapy related to osteomyelitis and listed interventions such as administering IV fluids per order, auscultating lung sounds, monitoring the IV site for infection, and notifying the physician of signs and symptoms of infection or complications. During interviews, the MDS LVN stated that the MDS assessment is intended to depict the care being provided to the resident and that all active diagnoses should be included. He explained that floor nurses were responsible for updating the MDS upon initiation of a new diagnosis and that he only reviewed the MDS quarterly. He further stated that if a diagnosis was missing from the MDS, he viewed it as a reimbursement issue rather than a risk to resident care and reported that he had not received in-services on accurate MDS completion. The Administrator stated that he primarily focused on the BIMS score and was unsure whether resident diagnoses had to be included in the MDS, acknowledging that omitting medical diagnoses would not show the resident’s full clinical picture. He indicated that floor nurses and MDS nurses were responsible for accurate completion of the MDS and could not recall the last in-service provided. The facility’s Resident Assessment policy stated that a comprehensive assessment would be completed when a significant change was determined based on RAI manual criteria, but the osteomyelitis diagnosis was not reflected on the resident’s discharge MDS.
Failure to Document NP/MD Notification of Osteomyelitis Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident with a diagnosis of osteomyelitis. The resident, an older male with diabetes mellitus with hyperglycemia and open wounds of the left foot and great toe, had been admitted to the facility in February 2025 and discharged in January 2026. Hospital records from February 2025 documented concern for and MRI-confirmed calcaneal osteomyelitis of the left foot and possible osteomyelitis of the left 5th toe, with a plan for antibiotic therapy. The resident’s discharge MDS showed moderately impaired cognitive skills for daily decision-making, indicating the resident required cues or supervision. On December 9, 2025, a facility progress note documented that the resident had a podiatry appointment. A podiatrist’s progress note (undated in the record) later indicated erosion of the left 5th toe consistent with osteomyelitis and stated that infectious disease would be consulted that day, noting the toe was stable. However, the facility’s progress notes dated December 10, 2025 contained no documentation of the podiatrist’s osteomyelitis diagnosis and no record that the NP/MD was notified of this diagnosis. A subsequent progress note dated December 12, 2025 documented that the resident was sent to the hospital for further evaluation of osteomyelitis because the VA infectious disease appointment was taking too long to schedule. Interviews with staff confirmed that facility practice and expectations required nurses to review outside provider notes, notify the NP/MD immediately of any new orders or diagnoses, and document this notification in a progress note. LVN A stated that the nurse receiving the resident from an outside appointment and whoever reviewed the progress note were responsible for informing the NP and documenting the notification, and that failure to do so could result in delay in care and miscommunication. LVN B reported he was not aware of the osteomyelitis diagnosis until informed by the resident’s POA on December 12, 2025 and acknowledged that nurses were expected to notify the NP immediately of changes and document this, though he did not always document a note if there were no new orders. The DON stated that, in this case, she did not believe immediate NP notification was necessary because the podiatrist’s note contained no new orders and described the condition as stable, and she considered next-day notification acceptable. The Administrator, however, stated that staff were to notify the nursing supervisor and NP immediately of any new orders or changes in diagnosis and document a progress note. Review of the facility’s October 2021 “Medical Record Documentation” policy showed that licensed staff and interdisciplinary team members were required to document observations and services provided in the resident’s medical record in accordance with state law. The absence of documentation of NP/MD notification of the osteomyelitis diagnosis on December 10, 2025 constituted the cited deficiency.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the State Survey Agency as required. Specifically, when a resident alleged that an LVN squeezed her left hand, resulting in bruising, the facility did not report this allegation to the State Survey Agency within the mandated two-hour timeframe. The incident was documented by staff, and the resident demonstrated and described the alleged abuse, with staff noting that the bruises appeared consistent with fingerprints. Despite this, the facility did not treat the allegation as reportable abuse at the time. The resident involved had a complex medical history, including venous insufficiency, generalized anxiety disorder, delusional disorders, muscle wasting and atrophy, muscle weakness, and heart failure. She was noted to have aggressive behaviors, including attempts to hit staff, verbal aggression, and refusal of care and medications. On the day of the incident, staff observed multiple bruises on her left hand, and the resident reported pain and described her hand being squeezed by a nurse. Staff notified supervisors and the DON, and an x-ray was ordered, but the incident was not reported to the State Survey Agency as an abuse allegation within the required timeframe. Interviews with staff revealed confusion and disagreement about whether the incident constituted abuse and whether it should have been reported. The DON and Administrator reviewed the situation and determined, based on documentation of the resident's combative behavior, that the bruising could be explained by the resident's actions rather than abuse. As a result, the alleged perpetrator was not suspended, and the incident was not reported as required by facility policy and regulation. The facility's own policies require immediate reporting of all abuse allegations, but this process was not followed in this case.
Failure to Complete Required Annual Employee Registry Screenings
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not completing required annual employee misconduct registry (EMR) and nurse aide registry (NAR) screenings for two certified nurse aides (CNAs). According to the facility's policy, EMR and NAR screenings must be conducted upon hire and annually for all employees, including contracted staff, students, volunteers, and consultants, with documentation maintained as proof. Record reviews and interviews revealed that CNA A, hired on 03/26/24, had only one EMR/NAR screening completed on 03/20/2024, with no evidence of an annual screening in the employee file. Similarly, CNA B, hired on 05/01/18, had the last EMR/NAR screening on 01/31/24, with no documentation of an annual screening as required. Interviews with the HR Resource Assistant and HR Business Partner confirmed that annual EMR/NAR screenings had not been completed for CNA A and CNA B, and that such checks should be performed upon hire and annually according to facility policy. The Administrator also acknowledged that the screenings were not completed as required. This failure to follow established screening procedures could place residents at risk for abuse, neglect, exploitation, and misappropriation of property, as the facility did not ensure ongoing verification of employee eligibility and background in accordance with its own policies.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents for two residents reviewed for quality of care. For one resident with severe cognitive impairment, right-sided hemiparesis, and a history of falls, the call light was not within reach, assist bars were not in place, and the bedside table was positioned away from the resident. This resident required maximal assistance for bed mobility and had documented interventions for fall risk, including the use of assistive devices and call light placement. On the day of the incident, the resident was found on the floor after an unwitnessed fall from bed, with subsequent pain and abrasions, and was sent to the hospital for evaluation. Observations and interviews confirmed that the call light was not accessible and the bedside table was not appropriately positioned, contrary to the care plan and facility policy. Another resident, who was cognitively intact but required substantial assistance for bed mobility due to morbid obesity, osteoarthritis, and COPD, did not have a PT/OT evaluation completed for the use of assist bars after new beds were installed. This resident had previously used bed rails to assist with mobility and reported a loss of independence after their removal. The facility had not completed the required side rail assessment or therapy evaluation to determine the need for assist bars, resulting in the resident waiting for staff assistance for bed mobility. Interviews with staff and the resident confirmed that the lack of assist bars affected the resident's ability to move independently in bed. Facility staff interviews revealed that the process for evaluating and installing assist bars was delayed due to the arrival of new beds and pending therapy assessments. Maintenance staff were waiting for therapy's list before installing assist bars, and clinical leadership acknowledged that therapy evaluations were progressing slowly. The facility's policies required individualized assessments and interventions for fall prevention and side rail use, but these were not consistently implemented for the affected residents, leading to unmet care needs and increased risk for accidents.
Failure to Ensure Nursing Staff Competency in Blood Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets to provide safe and appropriate care to residents, as evidenced by two specific incidents involving a registered nurse (RN). In the first incident, the RN delegated the task of checking a resident's blood glucose level to a certified nurse aide (CNA), despite facility policy and in-service training explicitly prohibiting CNAs from performing this task. The RN, who had prior experience in an acute hospital setting where CNAs were permitted to check blood sugars, was unaware of the restriction in the long-term care setting. The CNA, also previously employed in a hospital, was similarly unaware of the policy. The blood glucose check was performed by the CNA, and the RN subsequently administered insulin based on the result provided by the CNA. In the second incident, the same RN administered an insulin injection to another resident in the main dining room by injecting through the resident's shirt without cleaning the injection site. The RN admitted to this practice, stating that he was rushing and did not want to roll up the resident's sleeve in the dining room. The RN acknowledged that this was not in accordance with his training and recognized that the injection site should have been cleaned prior to administration. The incident was observed and reported by a restorative CNA, who noted that the resident was startled by the injection and that the site was not cleaned before the injection was given. Interviews and record reviews revealed that the facility did not have a skills checklist specific to insulin administration for licensed staff at the time of the incidents. Additionally, there was a lack of written documentation regarding the investigation and re-education of staff involved in these incidents. The facility's policy on medication administration required medications to be administered as ordered and in accordance with manufacturer specifications, which include proper site selection and cleaning prior to injection. The events described demonstrate that the RN did not follow established facility policies and procedures in both delegating tasks and administering injections.
Failure to Administer Insulin According to Physician Orders and Manufacturer Guidelines
Penalty
Summary
A deficiency occurred when a resident with a history of dementia and type 2 diabetes did not receive insulin according to physician orders. The resident was admitted with orders for blood glucose checks before meals and administration of sliding scale insulin based on those results. On one occasion, the assigned LVN failed to check the resident's blood glucose before dinner and, as a result, did not administer the prescribed insulin. The LVN later stated that she was occupied with a medical emergency involving another resident and was unable to perform the required blood glucose check and insulin administration as ordered. On a separate occasion, the same LVN administered rapid-acting insulin to the resident well before the scheduled dinner time, and the resident did not receive a meal or snack within the recommended timeframe after insulin administration. The insulin was given at approximately 4:08 p.m., but the resident did not receive his dinner tray until about 5:15 p.m., exceeding the recommended interval for providing food after rapid-acting insulin. Facility policy and manufacturer specifications require that a meal or substantial snack be provided within 15 minutes of administering rapid-acting insulin to prevent hypoglycemia. Observations and interviews confirmed that the resident was non-verbal, had significant cognitive impairment, and required assistance with feeding. Staff interviews revealed inconsistent knowledge and practices regarding the timing of blood glucose checks and insulin administration relative to meals. Documentation showed that the required procedures were not followed, resulting in significant medication errors for the resident.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations involving misappropriation of resident property were reported to the State Survey Agency as required. Specifically, a male resident with intact cognition reported his wallet, containing identification documents, a Social Security card, a checkbook, and approximately $180, as missing. The initial report of missing items was documented, and some items were found and returned. However, when the wallet and additional items were reported missing again, the facility did not report the incident to the State Survey Agency, despite the policy requiring such reporting for all allegations of misappropriation. The investigation included interviews with the resident, his spouse (who was also a resident and had severe cognitive impairment), and staff. The resident suspected his spouse, who had a history of wandering and confusion, may have taken the wallet without consent, but she was unable to recall or communicate about the incident. Staff and the social worker conducted searches of the resident's room, the spouse's new room in memory care, the laundry, and common areas, but the wallet was not located. The resident monitored his financial accounts and canceled his cards, reporting no unauthorized activity. The administrator acknowledged awareness of the requirement to report missing items to State Operations but determined that, in this case, the lack of a clearly identified perpetrator and the possibility of the wallet being misplaced rather than deliberately taken did not meet the threshold for misappropriation. The facility's policy defined misappropriation as the deliberate misplacement or wrongful use of a resident's belongings without consent and required immediate investigation and reporting of such allegations. Despite this, the incident was not reported to the State Survey Agency as required by policy.
Failure to Serve Meals Simultaneously in Memory Care Unit
Penalty
Summary
The facility failed to treat residents with respect and dignity by not serving meals simultaneously to all residents at the same table in the memory care unit. During an observation, it was noted that residents had to wait up to 30 minutes for their meals while their tablemates were already eating. This discrepancy in meal service was observed across multiple tables, affecting 7 out of 15 residents reviewed for residents' rights. The delay in serving meals led to situations where some residents had consumed a significant portion of their meals while others at the same table had not yet been served. Interviews with the Director of Nursing (DON), a Pharmacy Nurse, and the Interim Certified Dietary Manager (CDM) revealed that the responsibility for ensuring simultaneous meal service lies with the nursing and kitchen staff. The DON acknowledged the unfairness of the situation and emphasized the need for nursing staff to notify the kitchen about pending trays. The Pharmacy Nurse and Interim CDM confirmed that the nursing staff, with assistance from administrative staff, are responsible for passing trays and ensuring all residents at a table are served together. The facility's policy on resident rights underscores the importance of treating residents with respect and dignity, which was not upheld in this instance.
Deficiency in Resident Grievance Process Awareness
Penalty
Summary
The facility failed to ensure that residents were aware of the grievance process, as evidenced by interviews and record reviews. During a Resident Council meeting, five out of twelve residents reported not knowing how to file a grievance or who was responsible for handling grievances. The residents stated that they had not been informed about the grievance process during their admission, and the Resident Council Minutes from August 2024 to January 2025 showed no discussion of grievance policies or resident rights. Interviews with facility staff, including the Activities Director, Social Worker, LVN, Director of Admissions, DON, and Administrator, revealed inconsistencies in the communication and education of the grievance process to residents. The Activities Director admitted to not recording discussions about filing grievances in the meeting minutes, and the Social Worker acknowledged a lack of records on assisting residents with grievances. The Director of Admissions and LVN expressed uncertainty about how residents were informed of the grievance process, while the DON and Administrator recognized the need for improvement in educating residents on filing grievances. The facility's policy on Resident Rights, dated February 2020, states that residents should be notified of their right to file grievances both orally and in writing, with contact information for independent entities provided. However, the report indicates that this policy was not effectively communicated to residents, leading to a deficiency in ensuring residents' awareness of the grievance process.
Failure to Post Oxygen Signs in Resident Rooms
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents who required oxygen therapy, as observed by the absence of oxygen signs outside their rooms. Resident #68, an elderly male with a history of dementia, pulmonary embolism, and other respiratory conditions, was using oxygen in his room without a sign posted outside. Similarly, Resident #142, an elderly female with severe cognitive impairment and multiple health issues, also had an oxygen concentrator in her room without the required signage. Interviews with various staff members, including LVNs, CNAs, the RN Supervisor, the Activities Director, and the DON, confirmed that the facility's policy required oxygen signs to be posted outside rooms where oxygen concentrators were in use. The absence of these signs was acknowledged by the staff, who recognized the potential risks, including unchecked oxygen levels and fire hazards, particularly in the case of Resident #68, who was noted to be a smoker. The facility's Oxygen Administration Policy, dated February 2015, mandates the placement of non-smoking signs outside residents' rooms to prevent fire hazards and ensure proper monitoring of oxygen levels. Despite this policy, the deficiency was observed, indicating a lapse in adherence to established safety protocols, as confirmed by the facility's staff and administration during interviews.
Deficiencies in Pharmaceutical Services and Record-Keeping
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several deficiencies in medication administration and record-keeping. Specifically, the facility did not ensure that licensed staff signed the Controlled Drugs-Audit Record form after counting and verifying all controlled substances in the medication cart during shift changes. Additionally, a licensed staff member failed to update the individual control drug record after administering controlled medication to a resident, resulting in an inaccurate count of medication. This discrepancy was observed when the remaining amount of Tramadol in the blister packet did not match the count on the control drug record. Furthermore, the facility did not ensure that the temperature log for vaccines and medications was signed after verifying the correct refrigerator temperature. This lapse in procedure was noted in the medication room, where the temperature log was not signed for the morning shift. These failures in documentation and procedure could potentially place residents at risk for not receiving the intended therapeutic response of prescribed medications and increase the risk of drug diversion of controlled substances.
Medication Storage Deficiency Due to Unclean Bottles
Penalty
Summary
The facility failed to ensure the proper storage and cleanliness of medication and treatment carts, which was observed during a survey. Specifically, liquid medications stored in medication carts on three different halls (300, 700, and 800) were found with dried drippings on the sides of the bottles. This included bottles of ProStat and Valproic acid. Additionally, a treatment cart contained a bottle of povidone iodine with similar dried drippings. Interviews with the Licensed Vocational Nurses (LVNs) responsible for these carts revealed that they were trained to keep medication bottles clean to prevent cross-contamination, yet the bottles were not maintained as such. The Director of Nursing (DON) confirmed that nurses were trained to keep medication carts clean and to store medications by route, with liquid bottles kept clean and upright. However, the facility's policy and procedure on Storage and Expiration Dating of Medications and Biologicals did not provide specific instructions on maintaining bottles free of dried drippings. The presence of dirty bottles in the medication carts posed a potential risk for bacterial contamination, which could affect residents receiving medications at the facility.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to provide meals at an appetizing and safe temperature during a lunch service, as observed on January 28, 2025. The deficiency was noted for pureed, regular, and mechanical soft meals, specifically involving fried zucchini and Albondiga (meatball) soup, which were served below the acceptable hot food temperature of 135°F. The pureed diet items were recorded at 131°F and 131.2°F, while the regular diet fried zucchini was at 123°F, and the mechanical soft diet fried zucchini was at 126.1°F. This failure was identified during an observation and interview with the CDM Interim, who acknowledged the temperature readings and the facility's policy requiring hot foods to be served at 135°F or higher. The CDM Interim admitted to forgetting the thermometer and alcohol swabs needed for accurate temperature readings and sanitation during the sampling process. He noted that the food had been in the cart for approximately 15 minutes, which contributed to the temperature drop. Despite the facility's policy on food holding and service, the CDM Interim expressed concern about the potential risks of serving food below the required temperature, including the possibility of foodborne illnesses such as salmonella. The facility's policy, dated October 2018, mandates that all hot foods be served at a temperature of 135°F or greater, highlighting a lapse in adherence to this standard during the observed meal service.
Inaccessible Call Light Poses Risk to Resident
Penalty
Summary
The facility failed to ensure that resident call lights were kept within reach, which resulted in a deficiency for one resident. During an observation, it was noted that the call light for a resident was tangled and lying on the floor, making it inaccessible. The resident confirmed that she could not reach the call light and would have to wait for a staff member to pass by to call for help. Interviews with various staff members, including CNAs, an RN, the Activities Director, an LVN, the DON, and the Administrator, revealed that all were aware of the policy requiring call lights to be within reach of residents. However, the policy was not adhered to in this instance. The resident involved was an elderly female with multiple health conditions, including generalized muscle weakness, coronary artery disease, hypertension, renal insufficiency, and obstructive uropathy. Her care plan specifically indicated that the call light should be within reach when she was in bed due to her risk of falls. Despite this, the call light was not accessible, posing a risk of unmet needs. The facility's policy, dated October 2019, stated that call lights should be functional and within reach to allow residents to call for assistance, but this was not followed in the case of the resident.
Incomplete Documentation of Behavioral Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which could potentially place them at risk of not receiving needed services or errors in treatment. For one resident, the facility did not document a behavioral incident in the Medication Administration Record/Treatment Administration Record (MAR/TAR) where the resident exhibited irritability and aggression by pulling a roommate's blanket and slapping the roommate. This incident was not recorded in the MAR/TAR despite being tracked for such behaviors every shift. Similarly, another resident's behavioral incident was not documented in the MAR/TAR. This resident hit another resident on the leg with a walker, an incident that was also supposed to be tracked for aggressive behavior related to delusional and impulse disorders. The Director of Nursing (DON) acknowledged that the MAR/TAR is used for making decisions regarding resident care planning and that the incidents should have been documented accurately. The facility's policy requires that documentation be completed at the time of service or no later than the shift in which the observation occurred.
Failure to Prevent UTI Due to Improper Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with a catheter. The resident, an elderly male with obstructive and reflux uropathy and benign prostatic hyperplasia, was observed with his catheter drainage collection bag lying on the floor. This observation was made by a Health and Human Services Investigator, and it was noted that the resident was asleep at the time. The facility's care plan for the resident included keeping the Foley bag off the floor, but this was not adhered to. Interviews with facility staff, including an LVN, ADON, and DON, revealed that the drainage bag should have been attached to the bedframe below the resident's bladder level to prevent infection and possible spills. The LVN acknowledged that the CNAs had recently changed the resident but failed to reattach the drainage bag properly. The ADON and DON confirmed that it was the responsibility of the nursing staff, including CNAs, to ensure the drainage bag was off the floor. The facility's catheter care policy emphasized maintaining proper technique to prevent infections, but this was not followed in this instance.
Failure to Post Oxygen Use Sign for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen management, as observed during a survey. The resident, an elderly male with a history of acute upper respiratory infection and obstructive sleep apnea, was admitted to the facility and had an order for oxygen therapy at 2-3 liters per nasal cannula as needed for shortness of breath or comfort. Despite the care plan indicating the need for a 'No Smoking' sign on the resident's door while oxygen was in use, no such sign was present during the observation. The Assistant Director of Nursing (ADON) acknowledged the absence of the required 'Oxygen in Use' sign, which was a responsibility shared with the floor nurse. The ADON admitted to not knowing why the sign was missing and noted that the purpose of the sign was to inform others of the oxygen use in the room. The facility's Oxygen Therapy policy, dated 2012, also required the placement of such signs. The lack of signage could potentially lead to an unsafe environment, although the ADON considered the risk minimal due to the facility's smoke-free status.
Failure to Document PRN Oxygen Order
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding a physician's order for PRN oxygen. The resident, an elderly male with acute upper respiratory infection and obstructive sleep apnea, was admitted to the facility and required oxygen therapy. On a specific date, the resident's oxygen levels dropped, prompting a nurse to administer oxygen and notify the RN Supervisor. However, the nurse did not document the physician's order for PRN oxygen in the system, which was a requirement according to the facility's policy. The Director of Nursing (DON) confirmed the absence of the order in the system and acknowledged that the nurse was busy stabilizing the resident and forgot to enter the order. The Nurse Practitioner (NP) had given a verbal order for PRN oxygen, but it was not documented by the nursing staff. This oversight could have led to treatment errors, as other staff members might not have been aware of the resident's need for oxygen. Despite the documentation failure, the resident received continuous oxygen, and there was no negative outcome reported.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care. Resident #8's quarterly MDS assessment did not account for his g-tube status, despite his care plan indicating a need for feeding related to dysphagia. The Unit Manager confirmed that Resident #8 had a g-tube since admission, and the MDS Nurse acknowledged the oversight. This inaccuracy could affect the resident's nutritional and hydration status management. Similarly, Resident #16's quarterly MDS assessment did not reflect his behavior of making false accusations, even though his care plan noted repeated criticism of staff. The Unit Manager and MDS Nurse both confirmed awareness of these behaviors, yet the MDS assessment failed to include them. This omission could impact the staff's ability to manage and document the resident's behavioral issues effectively. Both inaccuracies were attributed to errors in the MDS assessments, which are reviewed quarterly, annually, and yearly by the MDS Nurses.
Failure to Implement Care Plan for Resident's Behavior
Penalty
Summary
The facility failed to implement care interventions in accordance with the written plan of care for a resident who exhibited behavior of pulling on a drainage tube. Despite the resident's history of pulling on the drainage tube, this behavior was not addressed in the care plan. The resident, who was cognitively intact with a BIMS score of 11, had multiple incidents of pulling on the drainage tube, which led to the tube being dislodged and required medical intervention. The staff, including CNAs and LVNs, were aware of the behavior and took measures such as frequent rounding, moving the resident closer to the nurse's station, and involving the family in monitoring. However, these interventions were not documented in the care plan. Interviews with staff revealed that the MDS nurse responsible for the resident's care plan was not aware of the behavior, despite it being discussed in daily morning meetings. The Unit Manager acknowledged that the behavior should have been included in the care plan to ensure proper monitoring. The facility's policy on care plans emphasizes the need to develop comprehensive, person-centered care plans that identify care needs and include individualized approaches. The failure to document and implement the behavior-focused interventions in the care plan represents a deficiency in the facility's compliance with its own policies and regulatory requirements.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not immediately suspend CNA B after CNA A reported suspected roughness when CNA B was providing care to a resident. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress. The resident involved was an elderly female with diagnoses of dementia, Alzheimer's, acute pain due to trauma, and anxiety. Her cognitive level was severely impaired, and she exhibited behavior symptoms like verbal/vocal symptoms such as screaming and disruptive sounds. On the day of the incident, CNA A reported that CNA B had grabbed the resident by her arms and pulled her strongly towards her. Despite this report, CNA B was allowed to continue working her shift and was only suspended after her shift ended. Interviews with the DON, Administrator, and other staff revealed inconsistencies in the handling of the incident. The DON and Administrator began investigating around lunchtime, gathering statements from staff, but did not immediately suspend CNA B. The facility's policy required immediate suspension of the alleged perpetrator pending investigation, but this was not followed. The investigation results were deemed unsubstantiated due to inconsistencies in CNA A's statements and lack of physical or emotional distress observed in the resident.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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