Avir At Adams
Inspection history, citations, penalties and survey trends for this long-term care facility in Temple, Texas.
- Location
- 3011 W Adams Ave, Temple, Texas 76504
- CMS Provider Number
- 675587
- Inspections on file
- 42
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Avir At Adams during CMS and state inspections, most recent first.
A resident with intact cognition and multiple medical conditions, requiring assistance with toileting and hygiene, reported being left in wet briefs for hours, especially at night, causing feelings of sadness, hopelessness, and helplessness. The care plan and skin assessments did not reflect adverse effects from prolonged exposure, but interviews with CNAs and an LVN confirmed that residents had complained of being left in soiled briefs and that staff sometimes found residents already soiled at shift start. The DON and Administrator stated they were unaware of such issues, expected frequent rounds and prompt call light response, and acknowledged limited documentation of incontinence care, while facility policy guaranteed residents a dignified existence and treatment with respect and dignity.
A cognitively impaired, nonverbal female resident with dementia and mobility limitations was found in bed in a male resident’s room with the male on top of her, both with pants down and the male thrusting, according to a med aide who intervened and separated them. Documentation described the female as unable to complete BIMS, nonverbal, and unable to consent, and the male as having dementia, schizophrenia, and prior intact cognition but exhibiting confusion, poor judgment, and impaired boundaries at the time. Staff notes and the facility’s self-report acknowledged the physical positioning and exposure but asserted no penetration, while a later skin check noted dried feces on the female’s pubic hair and her family reported being told that clothes were off and that she was not sent to the hospital until they requested it days later. Fifteen-minute monitoring logs for both residents were incomplete, staff interviews conflicted on whether the female wandered, whether she was on 1:1, how often rounding occurred, and knowledge of the incident, and the SW reported no psychosocial assessments or safety surveys were done, demonstrating a failure to provide adequate supervision and protection from abuse.
A cognitively impaired, nonverbal female resident with dementia and mobility limitations was found in bed with a male resident who was on top of her and thrusting, with both residents’ pants down and her brief still on. Staff separated the residents and documented physical and psychosocial assessments with no apparent injuries or signs of penetration, though dried feces were noted on the female resident’s pubic hair. Despite written abuse-prevention policies requiring protection and investigation of possible abuse, the female resident was not offered immediate emergency transport for medical evaluation after the alleged sexual assault and was only sent to the ED by EMS two days later at her family’s request for medical clearance related to possible STI exposure. The male resident, who had dementia and schizophrenia, was redirected and placed on 1:1 monitoring and later sent to another hospital, but the core deficiency centered on the facility’s failure to implement its abuse policies by not promptly offering emergency transportation services to the alleged victim.
A cognitively impaired, nonverbal female resident with dementia and mobility limitations was found in bed with a male resident who had dementia and schizophrenia, with both residents’ pants down and the male resident observed thrusting on top of her. Staff separated the residents and documented physical and psychosocial assessments, noting no obvious signs of penetration or acute distress, and the event was treated as an alleged abuse incident. However, the facility did not report this allegation of abuse involving both residents to the SSA and law enforcement within the required 2-hour timeframe, and the administrator’s narrative report was not submitted until later that evening, constituting a failure to timely report suspected abuse.
Two residents were found to be living in rooms that did not meet standards for cleanliness and comfort, with one room containing trash, stained sheets, and an unclean bathroom, and another room containing damaged furniture. Staff interviews revealed that rooms are cleaned daily and linens are changed on shower days, but cleaning and linen changes were sometimes missed, especially when a resident was resistant to care. Facility policy requires a clean and homelike environment, but these standards were not consistently upheld.
Two residents with cognitive impairment and psychosocial needs did not receive individualized activities as required. One resident did not have activity preferences assessed or documented, and did not receive planned one-on-one activities for several months. Another resident, who preferred in-room visits, did not consistently receive scheduled activities and expressed loneliness. Staff interviews confirmed a lack of assessment and documentation of preferences, and facility policy for individualized activity programming was not followed.
A resident with a sacral pressure ulcer did not receive dressing changes as ordered on multiple occasions, with nursing staff documenting care that was not performed. The wound dressing was found to be unchanged for several days, and staff interviews confirmed the lapse in care and documentation. The resident had multiple medical conditions and a care plan specifying wound care, but the facility did not ensure adherence to physician orders.
Nurses and nurse aides failed to follow facility policy requiring sterile technique for nephrostomy dressing changes for a resident with bilateral nephrostomy tubes. Staff were unaware of the sterile technique requirement, did not perform dressing changes as ordered, and had not received training on nephrostomy care. Observations confirmed the absence of dressings at the nephrostomy sites, and documentation showed staff signed off on care that was not provided.
A medication aide failed to accurately document the administration of several controlled substances on narcotic medication logs for multiple residents with complex medical needs. Although the medications were administered as prescribed, the required documentation was not completed at the time of administration, leading to discrepancies between medication counts and records. Staff interviews and medication reviews confirmed the issue was due to documentation errors rather than diversion.
Staff failed to follow proper hand hygiene protocols during food preparation and meal service, including a cook not changing gloves or sanitizing hands between tasks and staff distributing food trays to two residents without sanitizing their hands. Despite facility policies and staff awareness of hand hygiene requirements, these lapses were observed and confirmed through staff interviews.
Two residents did not have accurate or complete documentation of wound and nephrostomy site care. For one, scheduled dressing changes for a sacral pressure wound were not consistently performed or recorded correctly, with a nurse admitting to signing off on care that was not provided. For the other, dressing changes to nephrostomy sites were documented as completed, but observations and resident interviews confirmed that no dressings were present and the care was not performed as ordered. Facility policy requires accurate documentation of such care, but this was not followed.
The facility did not maintain an effective pest control program, resulting in the presence of gnats, roaches, and bed bugs in resident rooms and restrooms. A resident with multiple chronic conditions was found with bed bugs in personal belongings and linens, and staff observed pest activity throughout the building. Despite a pest control policy and contracted services, repeated pest sightings were documented without evidence of adequate follow-up.
A resident's personal and medical information was left visible on an unattended tablet at the medication cart for several minutes, allowing anyone passing by to view confidential data. Staff interviews confirmed awareness of privacy protocols, but the incident showed a failure to secure electronic health records as required.
Surveyors identified that two residents did not have accurate or complete MDS assessments: one resident's activity preferences were omitted due to failure to complete the required section and lack of outreach to caregivers or staff, while another resident's pressure ulcer was not documented in the assessment despite clear evidence in medical records and direct observation. These deficiencies were confirmed by staff interviews and review of facility policy.
Two residents who required staff assistance with ADLs, including nail care, were observed to have unclean and uneven fingernails despite requesting help. Staff interviews confirmed responsibility for nail care but revealed uncertainty about when care was last provided, and no refusals were documented. This failure to provide necessary hygiene services was not in accordance with the facility's policy or the residents' care plans.
A resident with nephrostomy tubes did not receive ordered sterile dressing changes, as staff failed to perform and document the care according to physician orders and facility policy. Nursing staff were unaware of the requirement for sterile technique, and no in-service training on nephrostomy care had been provided. The resident reported that only lotion was applied to her back, and observations confirmed the absence of dressings at the nephrostomy sites.
A resident with multiple health conditions and requiring significant assistance with daily activities experienced an 18-minute delay in call light response. Staff interviews confirmed that call lights are expected to be answered within 2 minutes, but on this occasion, the responsible CNAs were either occupied or unaware of the call. The facility's policy requires timely responses to resident requests, which was not followed in this instance.
A resident with dementia and behavioral issues was sent to the hospital after an incident and, despite being medically and psychiatrically cleared, was not allowed to return to the facility. The administrator refused readmission due to the resident's behaviors, and required 30-day discharge notices were not provided to the responsible party or ombudsman. Staff interviews confirmed the lack of proper notice and involvement in alternative placement, resulting in the resident remaining at the hospital until transfer elsewhere.
The facility failed to provide adequate hygiene care and services to three residents, leading to potential risks for their well-being. The residents, with varying degrees of cognitive and mobility impairments, did not consistently receive showers as per their care plans. Documentation was unclear, and staff interviews revealed confusion about the shower documentation process, contributing to the deficiency.
A facility failed to maintain the dignity of nine residents in the memory care unit when an LVN referred to clothing protectors as 'bibs,' a term associated with children. Despite staff training on using appropriate terminology, this incident occurred, potentially affecting residents' self-esteem. Interviews confirmed staff awareness of the importance of maintaining dignity, and facility policies emphasize respectful treatment and language.
The facility failed to maintain accurate records for controlled drug destruction, involving a medication aide (MA C) in the process without proper authorization. The forms lacked necessary pharmacist signatures, and staff interviews revealed a misunderstanding of policy requirements. The facility's policy requires licensed professionals to oversee drug destruction, but the pharmacist was not consistently present, leading to potential risks of drug diversion.
The facility failed to store disposable plates and cups away from cleaning supplies, risking cross-contamination and foodborne illness. Staff interviews revealed inconsistent training and adherence to storage protocols, despite awareness of the risks. The facility's policy mandates separate storage of food-related items and chemicals, which was not followed.
Failure to Provide Timely Peri Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely perineal care and maintain dignity for a cognitively intact resident who reported being left in soiled briefs for extended periods, particularly at night. The resident, an older female with diagnoses including paranoid schizophrenia, abnormalities of gait and mobility, groin furuncle, dehydration, anxiety disorder, and hypocalcemia, required assistance with toileting transfers and supervision or touching assistance with toileting hygiene. Her MDS indicated bowel continence and no toileting program, and her care plan did not reflect any adverse reactions from prolonged exposure to wet briefs. Despite this, she stated in an interview that she was often left sitting in a wet brief for hours, which made her feel sad, hopeless, and helpless, and that she had reported this to the DON and Administrator without any change. Interviews with staff revealed inconsistent awareness and documentation practices related to toileting and incontinence care. The DON reported being unaware of residents being left in soiled briefs for hours and stated that staff were expected to check residents frequently and respond to call lights as soon as possible, but also acknowledged that staff did not document how many times they provided supervision or touching assistance or changed briefs, only documenting complications or abnormal behavior. The Administrator stated that no residents had approached him about being left in wet briefs and that he expected staff to respond to call lights promptly and conduct rounds every two hours, noting that failure to respond appropriately could create poor quality and poor resident satisfaction. Direct care staff interviews corroborated resident concerns about delayed incontinence care. CNA A stated that leaving a resident in a soiled brief was a form of neglect, that he made rounds at least every two hours, and that residents had complained to him about being kept in wet briefs for too long; he reported these concerns to the charge nurse but had not seen an outcome, and specifically noted that this resident had mentioned being left in soiled briefs once or twice. CNA B reported that staff should make rounds every two hours, that she typically did so every hour, and that she could document peri care in the Point Click Care system; she also stated that she had come on shift several times to find residents sitting in soiled briefs and attributed this to lack of structure, not lack of time. LVN A reported that residents had told her they were often left in wet briefs during the daytime, and when she informed the DON, the DON denied it, stating it was not true. Although skin assessments did not show breakdown for this resident, staff interviews acknowledged that prolonged exposure to soiled briefs could cause skin breakdown, and the facility’s Accommodation of Need policy emphasized residents’ rights to a dignified existence and to be treated with respect, kindness, and dignity, which were not upheld in this case.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse by Co-Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a severely cognitively impaired, nonverbal female resident from sexual assault by a male co-resident and to ensure adequate supervision and monitoring on the memory care unit. The female resident had dementia, anxiety and depressive disorders, gait and mobility abnormalities, and required supervision or touching assistance with transfers, bed mobility, and lower body dressing. Her MDS showed she was unable to complete a BIMS interview, had short- and long-term memory problems, and was moderately impaired in daily decision-making. Her care plan identified wandering into other residents’ rooms and sometimes lying in other residents’ beds, with interventions directing staff to anticipate and meet needs, protect other residents’ rights and safety, divert and remove her from situations, and redirect her to her room or common areas when she entered other residents’ rooms. On the day of the incident, a medication aide reported that while passing medications she knocked, heard moaning, and entered the male resident’s room, where she observed him on top of the female resident in his bed. She stated both residents’ pants were down, the female resident’s brief was still on, the female resident was making noises and had a flushed face, and the male resident was thrusting against her. She told him to stop, after which he rolled off, and she separated the residents and called for assistance. Nursing documentation described the female resident as being found in bed with another resident, with staff intervening and separating them, and later noted that she was observed in a male resident’s room in bed with a male on top of her gyrating his hips. A subsequent skin check documented dried feces on the female resident’s pubic hair. The female resident was nonverbal, unable to meaningfully participate in BIMS, and could not be interviewed about the event. The male resident involved had vascular dementia, schizophrenia with auditory and visual hallucinations, and a BIMS score of 15 on his most recent MDS, indicating he was cognitively intact at that time. His care plan noted he resided on the secure unit due to wandering and poor safety awareness. On the day of the incident, nursing documentation for him stated he was observed lying in bed next to a female resident when staff intervened. An incident note (later struck out) described him as confused and disorganized with impaired judgment and poor personal boundaries at the time of redirection. The facility’s self-report narrative, matching the administrator’s note, stated that the medication aide found the male resident in bed with the female resident, his pants down with genitalia exposed, and the female resident’s pants down but brief intact, and that the male resident rolled to his side when told to stop. The administrator documented that no penetration was noted by the witness and no evidence of penetration was seen on physical examination, but the family of the female resident reported being told that a male resident was found on top of her with clothes off and her brief loosened, and that she was not sent to the hospital until they requested it two days later. The deficiency is further supported by inconsistent and incomplete monitoring and staff accounts regarding supervision and rounding on the memory care unit. Fifteen-minute check forms for both residents on the day of the incident contained only limited entries, with no documentation beyond early evening times. Staff interviews revealed conflicting statements about whether the female resident wandered, whether she was on 1:1 supervision, how often residents were rounded on (ranging from every 30 minutes to less than every two hours), and who the abuse coordinator was. Some CNAs denied knowledge of any resident-to-resident sexual abuse incidents, despite the documented event. The assistant DON acknowledged being told that a staff member walked in on the male resident on top of another resident having sexual intercourse but did not know if 1:1 monitoring was implemented. The social worker stated she did not conduct psychosocial assessments or safety surveys for the involved residents after the allegation. These actions and inactions demonstrate that the facility did not ensure adequate supervision, timely assessment, and protection of the female resident’s right to be free from abuse and neglect. Additional information from interviews with the residents’ representatives underscores the nature of the event and the facility’s response at the time of the deficiency. The female resident’s MPOA stated she was unable to get up on her own and was not a wanderer, and that they were notified by phone that a male resident was found on top of her with clothes off and her brief loosened. They reported learning two days later that she had not been sent to the hospital on the day of the incident and that they had to request hospital evaluation. The male resident’s responsible party reported being told that staff caught him sexually assaulting another female resident and that he was sent to the ER because he was distraught, and also stated staff told them this was not the first incident involving him. These documented accounts, combined with the clinical records and staff statements, show that the facility failed to protect the female resident from sexual abuse by another resident and failed to provide consistent supervision and timely, thorough assessment in accordance with the residents’ conditions and care plans. The survey findings also note discrepancies in documentation of the male resident’s cognitive status and behavior. While his quarterly MDS showed a BIMS of 15 and no behavioral symptoms, nursing notes around the time of the incident described him as having a BIMS of 6 with severe cognitive impairment, confusion, disorganized behavior, and poor personal boundaries. The administrator’s note and the facility’s self-report both referenced his low BIMS score and cognitive impairment, yet staff interviews varied on whether he wandered or could give consent. The lack of clear, consistent assessment and monitoring of his behaviors and risks, combined with the failure to prevent or promptly and comprehensively respond to the observed sexual contact with a vulnerable, nonverbal resident, constitutes the core of the deficiency identified by surveyors.
Failure to Implement Abuse Policy and Offer Timely Emergency Transport After Alleged Sexual Assault
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its written abuse, neglect, exploitation, and misappropriation prevention policies in response to an alleged sexual assault between two residents. The facility’s policy, revised April 2021, states residents have the right to be free from abuse and neglect, requires protection from abuse by other residents, mandates identification and investigation of all possible incidents of abuse, and requires protection of residents from further harm during investigations. Despite these written policies, the facility did not ensure that a cognitively impaired, nonverbal female resident was offered emergency transportation services for medical evaluation immediately after she was found in bed with a male resident who was on top of her and gyrating his hips. The female resident had dementia, anxiety disorder, major depressive disorder, pain disorder, gait and mobility abnormalities, and required supervision or touching assistance with transfers, bed mobility, and lower body dressing. Her MDS showed she was unable to complete a BIMS interview and had short- and long-term memory problems, with moderately impaired decision-making. Her care plan documented wandering into other residents’ rooms and lying in other residents’ beds, with interventions including redirection and protection of other residents’ rights and safety. On the date of the incident, staff notes documented that she was found in bed with another resident, that staff intervened and separated them, and that she was nonverbal but calm and cooperative. A head-to-toe and skin assessment documented no injuries or signs of penetration, but dried feces were noted on her pubic hair. Another psychosocial note described her as being in a male resident’s room with the male on top of her gyrating his hips, after which residents were separated and vital signs were within normal limits. The male resident involved had vascular dementia, schizophrenia, and auditory and visual hallucinations, and resided on the secure unit due to wandering and poor safety awareness. His MDS showed he was cognitively intact by BIMS score, independent in mobility and lower body dressing, and his care plan required monitoring and reporting changes in behavior. A change in condition note documented that he was observed lying in bed next to a female resident when staff intervened. An administrative note recorded that a medication aide entered his room, found him in bed with the female resident, his pants down with genitalia exposed, and the female resident’s pants down with her brief intact, and that he was immediately redirected and placed on 1:1 monitoring. The facility’s self-report and incident documentation focused on the event and internal assessments but did not reflect that the female resident was offered immediate emergency transport for medical evaluation after the alleged sexual assault. Subsequent documentation showed that the female resident was ultimately transported to the hospital by EMS for medical clearance related to possible STI exposure, but this occurred only after her family requested transfer two days after the incident. The hospital record indicated she presented for medical clearance due to a recent history of possible abuse, with the family reporting that a co-resident had been found on top of her in bed several days earlier. Interviews with the resident’s family and MPOA confirmed they were notified by staff of a male resident being found on top of her with clothing off, and that they later discovered she had not been sent to the hospital at the time of the incident and had to request that she be transferred. The survey findings state that the facility failed to implement written policies and procedures in response to the sexual assault in that the resident was not offered emergency transportation services after the abuse incident, contributing to the cited deficiency under the requirement to develop and implement policies and procedures to prevent abuse, neglect, and theft.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report alleged abuse involving two residents to the State Survey Agency (SSA) and law enforcement within the required 2-hour timeframe. A cognitively impaired, nonverbal female resident with dementia, anxiety, depression, gait abnormalities, and a BIMS score of 99 (unable to assess) was care planned for wandering and required supervision or touching assistance with transfers, bed mobility, and lower body dressing. On the date of the incident, a medication aide entered a male resident’s room during medication pass and observed the male resident on top of the female resident in his bed, with both residents’ pants down, the female resident’s brief still on, and the male resident thrusting his hips. The aide reported hearing moaning, noted the female resident’s flushed face and noises, and immediately separated the residents and called for assistance from other staff. Subsequent nursing documentation for the female resident described her as nonverbal, severely cognitively impaired, and unable to meaningfully participate in a BIMS assessment. Nursing notes indicated that staff completed a head-to-toe physical and skin assessment, documented no signs of penetration or genital injury, and noted dried feces on the resident’s pubic hair. Psychosocial assessments documented no acute distress based on observation of nonverbal behaviors. The incident was recorded as an alleged abuse event in the facility’s incident report log, with the time of occurrence documented in the afternoon. The resident’s family later reported being notified by phone that a male resident had been found on top of her with clothing off and her brief loosened, and they stated that the resident was not sent to the hospital the day of the incident and that they only learned two days later that she had not been evaluated in the emergency department at the time of the event. The male resident involved had vascular dementia, schizophrenia, auditory and visual hallucinations, and a documented BIMS score of 15 on a prior MDS, but facility notes around the incident described him as having a BIMS score of 6, indicating severe cognitive impairment. He resided on the secure unit for wandering and poor safety awareness. A change in condition note documented that he was observed lying in bed next to the female resident when staff intervened. Administrative documentation described him as found in bed with his pants down and genitalia exposed, with the female resident’s pants down but brief intact, and stated that there was no evidence of penetration on physical examination. The administrator’s narrative, which was later used as the self-report narrative to the SSA, was not sent to the SSA until the evening, and the administrator emailed the SSA stating that the website was down and he was unable to submit the report directly at the time. Interviews with staff and the social worker showed inconsistent knowledge of the incident details and of reporting timeframes, and the survey findings concluded that the facility failed to report the alleged abuse incidents involving both residents to the SSA and law enforcement within 2 hours after the abuse was observed.
Failure to Maintain Clean and Homelike Resident Environments
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents. Observations revealed that one resident's room contained several pieces of trash on the floor, dirty bed sheets with multiple stains that appeared unchanged for several days, and a bathroom with trash on the floor and fecal stains on the toilet seat. The same resident's room and bathroom were later found to be cleaned, but the bed sheets remained unchanged. The resident expressed dissatisfaction with the dependability of the staff and declined further conversation. In another room, the armoire was observed to be old, with peeling paint and holes, and the resident confirmed it had been in that condition for some time without requesting a replacement. Interviews with housekeeping and nursing staff indicated that rooms are cleaned once daily and sheets are typically changed on shower days. Staff reported that the first resident is often resistant to having his room cleaned or sheets changed, so these tasks are performed when he is not present, such as when he is outside smoking. Despite this, the room was not always cleaned or the sheets changed when the resident was absent. Facility policy requires a clean, sanitary, and homelike environment, including clean bed and bath linens, but these standards were not consistently met for the two residents observed.
Failure to Provide Individualized Activities Program for Residents
Penalty
Summary
The facility failed to provide an ongoing activities program that met the individual needs and preferences of two residents, resulting in a lack of both group and one-on-one activities. For one resident with severe cognitive impairment and reduced mobility, there was no evidence that activity preferences were assessed or documented, and no initial activity assessment was completed. The resident's care plan indicated a need for one-on-one activities, but records showed that these were not provided or documented for several months. Observations revealed the resident spent extended periods without stimulation, either in her room or in the common area, and staff interviews confirmed a lack of knowledge regarding her activity preferences. Another resident, who had moderate cognitive impairment, depression, and anxiety, was care planned to receive one-on-one activities twice per week, as he preferred in-room visits and did not participate in group activities. However, activity records indicated that the scheduled one-on-one visits were not consistently provided during the review period. The resident expressed a desire for more frequent visits and reported feelings of loneliness, particularly in the afternoons. He also stated that no one had asked him about his preferences for in-room visits, and the activities provided did not align with his stated interests. Interviews with the Activity Director and other staff confirmed that both residents were on the in-room activity program but did not consistently receive the activities as planned. The Activity Director acknowledged not documenting refusals or consistently assessing preferences, and was unaware of the specific desires of the residents. Facility policy required individualized activity programs and proper documentation, but these were not followed, resulting in unmet psychosocial and emotional needs for the residents involved.
Failure to Complete Pressure Ulcer Dressing Changes as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services consistent with professional standards of practice. Specifically, dressing changes for a sacral pressure ulcer were not completed as ordered on three separate dates. Documentation on the Treatment Administration Record (TAR) indicated that wound care was signed off as completed by nursing staff on certain dates, but observation and interviews revealed that the dressing had not been changed and the care was not actually provided. The dressing removed from the resident was dated several days prior, confirming the lapse in care. Nursing staff acknowledged that wound care was not performed as documented and recognized that this was not in accordance with facility expectations or physician orders. The resident involved was an older female with multiple diagnoses, including schizoaffective disorder, vascular dementia with anxiety, pain, and functional quadriplegia. Her care plan included specific interventions for pressure ulcer management, and physician orders detailed the required wound care regimen. Despite these orders, the facility did not ensure that dressing changes were completed as scheduled, and the facility's policy did not provide clear guidance on following wound care orders. Interviews with staff and administration confirmed that the expected standard was not met, and documentation did not accurately reflect the care provided.
Failure to Ensure Staff Competency in Nephrostomy Care
Penalty
Summary
Licensed nurses and nurse aides at the facility failed to demonstrate the necessary competencies and skills to provide appropriate nephrostomy care for a resident with bilateral nephrostomy tubes. Despite facility policy requiring sterile technique for dressing changes, multiple staff members, including LVNs, an RN, and the ADON, were unaware of this requirement and did not perform dressing changes using sterile technique. Interviews revealed that staff either did not change the dressings at all or used non-sterile methods, and there was a lack of knowledge regarding the facility's nephrostomy care policy. The resident involved was an older female with a history of hydronephrosis, chronic kidney disease, urinary tract infection, and type 2 diabetes. Her care plan and physician orders specified nephrostomy site care with sterile dressing changes twice daily. However, observations on multiple days showed that there were no dressings present at either nephrostomy site, and the resident reported that staff only applied cream or lotion to her back, with no dressing changes performed as ordered. Documentation indicated that staff signed off on dressing changes that were not actually completed. Further review found that the ADON, RN, and DON were not aware of or had not provided training on the facility's nephrostomy care policy, and there had been no in-services on this topic in the past six months. The DON acknowledged that staff were not trained on nephrostomy care upon hire and that she had not recently provided in-services on the policy. The facility had supplies available for sterile dressing changes, but staff did not utilize them due to lack of awareness and training.
Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate reconciliation and documentation of controlled medications for multiple residents. Specifically, a medication aide (MA B) did not accurately document the administration of several controlled substances, including tramadol, acetaminophen-codeine, oxycodone, lorazepam, methylphenidate, hydrocodone-acetaminophen, and clonazepam, on the narcotic medication logs for four residents. These discrepancies were identified during medication cart reconciliation and interviews, where MA B admitted to administering the medications but failing to record them due to being busy throughout the day. The affected residents had complex medical histories, including acute pain, stroke, intellectual disabilities, heart failure, chronic pain, schizoaffective disorder, bipolar disorder, dementia, and anxiety. Their care plans required timely and accurate administration and documentation of pain and psychotropic medications. Record reviews showed that the medication administration records indicated the medications were given, but the narcotic logs did not match the actual counts in the medication cards, revealing missing documentation for doses administered by MA B. Interviews with the DON, other nursing staff, and residents confirmed that the residents received their medications as prescribed, and no staff reported suspicious behavior or prior narcotic discrepancies. The DON and staff attributed the discrepancies to documentation errors rather than diversion, and a misplaced pill was found and destroyed. The facility's policy required detailed documentation of controlled substance administration, which was not followed in these instances, resulting in inaccurate narcotic logs for the residents involved.
Failure to Maintain Hand Hygiene and Kitchen Sanitation During Food Preparation and Service
Penalty
Summary
The facility failed to maintain proper kitchen sanitation and hand hygiene protocols during food preparation and service. On one occasion, a cook was observed preparing pureed noodles while wearing the same pair of gloves, using multiple kitchen utensils, touching a menu book, making notations with a pen, and opening the puree machine, all without changing gloves or sanitizing hands. The cook was also seen washing her hands while still wearing gloves and then continuing food preparation without replacing them. Staff interviews revealed that while some dietary workers recalled receiving in-service training on hand hygiene, at least one did not remember such training, though she acknowledged the importance of handwashing. During lunch service, staff distributed food trays to two residents without sanitizing their hands beforehand, only beginning to sanitize after serving those residents. Multiple staff members, including medication aides and a CNA, stated in interviews that they are required to wash or sanitize their hands before handling food trays and after touching non-clean surfaces. They also indicated that they receive in-service training on hand hygiene and would remind colleagues to clean their hands if they observed non-compliance. The facility's policy, as reviewed, requires staff to wash hands in warm soapy water for at least 20 seconds before and after touching food, and to clean utensils and surfaces after working with each food item. Despite these policies and staff awareness of the importance of hand hygiene, observations and interviews confirmed lapses in practice, specifically in the kitchen and during meal distribution to residents.
Incomplete and Inaccurate Documentation of Wound and Nephrostomy Care
Penalty
Summary
The facility failed to ensure complete and accurate documentation of wound care and dressing changes for two residents. For one resident with a history of schizoaffective disorder, vascular dementia, pain, and functional quadriplegia, there were inconsistencies and omissions in the Treatment Administration Record (TAR) regarding dressing changes to a sacral pressure wound. Specifically, no treatment was recorded on two scheduled dates, and a nurse admitted to signing off on a dressing change that was not performed. During observation, the dressing on the resident's wound was found to be dated from a previous week, indicating that scheduled changes may not have occurred as documented. For another resident with diagnoses including hydronephrosis, chronic kidney disease, and type 2 diabetes, the TAR reflected that dressing changes to nephrostomy sites were signed off as completed on two dates. However, both resident interviews and direct observations revealed that no dressings were present on the nephrostomy sites during those times, and the resident reported that only lotion was applied to her back. The nurse responsible for the documentation confirmed that she had not performed the dressing changes as recorded and had intended to do them later, but had already documented them as completed. Facility policy requires accurate documentation of wound care and nephrostomy tube care, including the date, time, and person performing the procedure, as well as the resident's response. Interviews with the Director of Nursing and the administrator confirmed that their expectation is for care to be provided and documented as ordered, and that incomplete or inaccurate documentation could result in residents not receiving necessary treatments.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats, roaches, and bed bugs in multiple areas, including resident rooms and restrooms. Observations included a half-eaten sandwich left unwrapped on an overbed table, which attracted gnats, and sightings of roaches crawling across the floor in a resident room. The pest control log documented repeated sightings of roaches, gnats, and other bugs throughout the facility over several months, with no evidence of follow-up services after these incidents. A resident with multiple medical conditions, including dementia, anxiety, depression, and chronic diseases, was found to have bed bugs in personal belongings and bed linens. The resident exhibited clusters of red, raised bumps with some skin breakdown due to scratching, as observed during a skin assessment. The care plan for this resident noted behavioral symptoms of hoarding, which complicated maintaining a safe and tidy living space. Staff discovered bed bugs crawling out of the resident's bible at the nurse station and further inspection revealed additional bed bugs in the resident's purse and linens. Interviews with staff confirmed awareness of ongoing pest issues, with documentation of pest sightings and communication to administration. The facility's pest control policy required ongoing pest management and regular contracted services, but records showed only monthly service visits and no documented follow-up after pest sightings. The pest control contract outlined responsibilities for monitoring, treating, and reporting pest issues, but the facility did not ensure the environment was free from pests, as evidenced by continued sightings and infestations.
Resident Health Information Left Visible on Unattended Medication Cart
Penalty
Summary
A deficiency was identified when a surveyor observed a medication cart with an open tablet displaying a resident's personal and medical information. The device was left unattended for at least five minutes during lunch service, allowing the resident's information to be visible to anyone passing by until the screen eventually timed out and went dark. This incident involved one resident whose information was exposed due to the failure to secure the electronic device as required. Interviews with medication aides, the administrator, and the director of nursing confirmed that staff are aware of the facility's policies and HIPAA requirements regarding the confidentiality of resident information. All interviewed staff acknowledged that leaving a laptop or tablet open with resident information visible is a violation of privacy and facility policy. Despite this, the observed incident demonstrated a lapse in following these protocols, resulting in the exposure of confidential health information.
Inaccurate and Incomplete Resident Assessments Identified
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the status of two residents during significant change Minimum Data Set (MDS) assessments. For one resident, the Significant Change MDS assessment did not include the resident's preferences for customary routines and activities. The Activity Director did not complete Section F (Activity Preferences) of the MDS, and did not contact the resident's caregiver or staff to obtain this information, despite the resident being unable to communicate her preferences directly. The omission was acknowledged by the Activity Director, who stated she forgot to complete the staff assessment, and it was confirmed that the resident's activity preferences were not documented anywhere in the electronic medical record. For another resident, the Significant Change in Status MDS assessment inaccurately indicated that the resident did not have any unhealed pressure ulcers, despite medical records, wound care orders, and direct observation confirming the presence of a stage 3 pressure ulcer to the sacrum. The MDS was signed by a staff member who was not a current employee at the time of the assessment. The staff responsible for MDS oversight admitted that the coding was an error and that wound care documentation at the time of the assessment clearly indicated the presence of a pressure ulcer. Interviews with facility leadership, including the DON and Regional MDS Consultant, confirmed that all sections of the MDS are expected to be completed accurately by the appropriate staff, and that information should be gathered from all available sources, including caregivers and staff. The facility's policy requires that each portion of the MDS be completed and certified for accuracy by qualified staff, and that the information must reflect the resident's status during the observation period. In both cases, the assessments were incomplete or inaccurate, failing to capture essential information about the residents' conditions and preferences.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically nail care, for two residents who were unable to perform these tasks independently. Both residents required staff support for personal hygiene, grooming, and other ADLs as documented in their care plans and assessments. Despite this, observations revealed that both residents had blackish/brownish substances under their fingernails and uneven nail edges, indicating that nail care had not been performed as required. Interviews with the residents confirmed that they had requested nail care assistance from staff, but their requests were not fulfilled. Staff interviews revealed that certified nursing assistants (CNAs) were responsible for nail care for most residents, while nurses handled nail care for residents with diabetes. Staff members acknowledged being in-serviced on nail care but could not recall when, and none reported that the residents had refused care. Documentation did not indicate any refusals, and staff were unable to specify when the last nail care was provided to these residents. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good grooming and hygiene. However, the lack of timely and adequate nail care for these two residents, as observed and confirmed through interviews and record reviews, demonstrated a failure to follow this policy and to meet the residents' assessed needs for assistance with personal hygiene.
Failure to Provide Sterile Nephrostomy Site Care per Orders and Policy
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, professional standards of practice, and the comprehensive care plan for a resident with nephrostomy tubes. The resident, an older adult with a history of hydronephrosis, chronic kidney disease, urinary tract infection, and type 2 diabetes, had physician orders for twice-daily sterile dressing changes to both nephrostomy sites. However, observations on two consecutive days revealed that no dressings were present at either nephrostomy site, and staff interviews confirmed that the ordered dressing changes were not performed on those days. Documentation in the Treatment Administration Record (TAR) indicated that dressing changes had been signed off as completed by an LVN, but the LVN admitted in interviews that she had not performed the dressing changes on the specified days and had signed off regardless. Further, the LVN and other nursing staff were unaware that sterile technique was required for these dressing changes, as specified in the facility's policy. Multiple staff, including the ADON and RN, reported not receiving training or in-services on nephrostomy care or the need for sterile technique, and the facility's in-service records for the past six months confirmed the absence of such training. The DON acknowledged that it was her expectation for staff to use sterile technique for nephrostomy dressing changes and that she had not ensured the dressing was applied after her assessment. The physician and administrator both stated that care should be provided per orders and policy, and that failure to do so could increase the risk of infection or deterioration of the stoma site. The resident herself reported that staff only applied lotion to her back and did not change the dressings as ordered.
Failure to Timely Respond to Resident Call Light
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's call light was answered in a timely manner, as required by the facility's policy and the resident's care plan. The resident, a cognitively intact female with diagnoses including epilepsy, COPD, major depressive disorder, anxiety, and a need for assistance with personal care, required substantial to maximal assistance with activities of daily living such as toileting, bathing, and dressing. During an observation, the resident activated her call light for assistance, but it was not answered for 18 minutes. The resident expressed ongoing concerns about delayed call light responses, stating that this had been an issue for months. Interviews with staff revealed that CNAs are expected to answer call lights within 2 minutes, and all staff are responsible for responding promptly. On the day of the incident, one CNA was occupied with dining room duties, while the other responsible CNA was unaware the call light had been activated. Both staff and administration acknowledged that prompt response is expected and that delays could result in residents' needs not being met. The facility's policy emphasizes the importance of timely responses to call lights to address residents' requests and needs.
Failure to Follow Required Discharge Procedures and Readmit Resident After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to permit a resident to remain in the facility and did not follow required transfer/discharge procedures. The resident, an older adult male with diagnoses including Alzheimer's disease, vascular dementia, asthma, and adjustment disorder, was admitted to the secured unit due to wandering and poor safety awareness. On the date of the incident, the resident became upset, attempted to leave the secured unit, and damaged the door. Police and EMS were called, and the resident was transported to the hospital for evaluation. The resident was medically and psychiatrically cleared for return to the facility, but the administrator refused to readmit him due to his behaviors. The facility did not provide a 30-day discharge notice to the resident's responsible party or the local ombudsman, as required by policy and regulation. Interviews with staff, including the HSW, BOM, LVN, and DON, confirmed that the resident was not allowed to return after hospital clearance, and that the responsible party was informed only after the resident was sent out. The responsible party was not given the opportunity to participate in finding alternative placement, and the resident remained at the hospital until transfer to another facility was arranged. The administrator acknowledged that a 30-day discharge notice was not provided and that this was expected practice. The facility's policy states that residents should not be transferred or discharged except in limited circumstances, and that proper notice must be given. The lack of notice and refusal to readmit the resident after hospital clearance constituted a failure to meet discharge requirements and ensure a safe and appropriate transition for the resident.
Inadequate Hygiene Care and Documentation for Residents
Penalty
Summary
The facility failed to provide necessary care and services to ensure that residents' abilities in activities of daily living (ADLs) do not diminish unless unavoidable due to clinical conditions. This deficiency was observed in three residents who were reviewed for ADLs. The facility did not ensure that these residents received adequate care and services for hygiene, which could potentially place them at risk for poor self-esteem, infections, socialization issues, ADL decline, and diminished quality of life. Resident #1, a female with severe cognitive impairment and multiple diagnoses affecting mobility and self-care, was not consistently provided with showers according to her care plan. The shower sheet logs for Resident #1 indicated inconsistencies in documentation, with several entries marked as 'Not Applicable' or 'Dependent,' and there was no clear indication of whether showers were actually provided. Interviews with staff revealed confusion and lack of understanding regarding the documentation process for showers. Resident #2, who is cognitively intact but requires assistance with personal care, reported not receiving help with showers or hair washing and stated that she had been in the same clothes for three days. The shower sheet logs for Resident #2 also showed inconsistencies, with multiple refusals and unclear documentation. Resident #3, with severe cognitive impairment and mobility issues, also had unclear documentation regarding shower provision. Interviews with CNAs and the DON highlighted a lack of clarity and understanding of the shower documentation process, contributing to the deficiency in care provided to these residents.
Failure to Maintain Resident Dignity in Memory Care Unit
Penalty
Summary
The facility failed to treat nine residents in the memory care unit with respect and dignity, as observed during a survey. The incident involved LVN A referring to clothing protectors as 'bibs' in the presence of the residents, which is considered disrespectful and diminishes the residents' dignity. This terminology is typically associated with children, and its use in this context could lead to residents feeling infantilized. Interviews with staff, including LVN A, CNA B, the ADON, the RNC, the SW, and the ADM, revealed that they were aware of the importance of using the term 'clothing protector' instead of 'bibs' to maintain residents' dignity. Despite this awareness, LVN A used the incorrect term, which was acknowledged as a mistake. The staff had been trained on dignity and the appropriate terminology, with the most recent in-service training occurring the previous month. The facility's policies on dignity and resident rights emphasize treating residents with respect and using appropriate language to ensure a dignified existence. The failure to adhere to these policies in this instance was noted, as it could potentially lead to psychosocial harm for the residents involved. The facility's records confirmed that staff had been in-serviced on these policies, highlighting the importance of maintaining residents' dignity and self-esteem.
Unauthorized Drug Destruction Process Involving Medication Aide
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs, which led to an inability to accurately reconcile these medications. This deficiency was identified during a review of the facility's drug destruction forms, where it was found that a medication aide (MA C) was involved in the drug destruction process without proper authorization. The forms lacked the necessary signatures from a licensed pharmacist, which is required to ensure compliance with federal and state regulations. Interviews with staff revealed that MA C, a medication aide, participated in the destruction of both controlled and non-controlled medications alongside the Director of Nursing (DON). Despite the facility's policy requiring the presence of licensed professionals during drug destruction, MA C was not authorized to perform these duties. The DON and other staff members, including the Administrator (ADM) and Licensed Vocational Nurses (LVNs), were unaware or misinformed about the policy requirements, leading to unauthorized personnel handling medications. The facility's policy mandates that drug destruction must occur in the presence of at least two licensed healthcare professionals. However, the pharmacist, who was supposed to oversee the process, was not consistently present or aware of MA C's involvement. This lack of oversight and adherence to policy could potentially lead to drug diversion, as unauthorized staff were involved in the handling and destruction of medications without proper documentation and verification by a licensed pharmacist.
Improper Storage of Disposable Items Near Chemicals
Penalty
Summary
The facility failed to store food-related items in accordance with professional standards for food service safety, as observed in the kitchen's cleaning supply room. Disposable plates and cups were stored next to cleaning supplies, including various degreasers, bleach, and other chemicals, which were not secured in a locked area. The room door was propped open, and no dietary staff were present to monitor the area. This improper storage practice was acknowledged by several staff members, including dietary aides, the dietary manager, and the director of nursing, who all recognized the risk of cross-contamination and potential foodborne illness. Interviews with staff revealed a lack of consistent training and adherence to proper storage protocols. Dietary staff, including DA F and the DM, admitted that the disposable items were placed in the cleaning supply room due to space constraints and weather conditions, despite knowing the importance of storing them separately from chemicals. The DM stated that staff were trained on proper storage six months prior, but the training did not prevent the current issue. The DC and other staff members also acknowledged the importance of keeping disposable items away from chemicals to prevent contamination. The facility's Food Storage policy, revised in 2019, clearly outlines the need to store items away from cleaning materials to avoid contamination. However, the policy was not followed, as evidenced by the storage of disposable plates and cups in the cleaning supply room. The facility's failure to adhere to its own policies and procedures, as well as state and federal guidelines, placed residents at risk of exposure to harmful chemicals through cross-contamination of food service items.
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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