Avir At Lindale
Inspection history, citations, penalties and survey trends for this long-term care facility in Lindale, Texas.
- Location
- 13905 Fm 2710, Lindale, Texas 75771
- CMS Provider Number
- 745021
- Inspections on file
- 23
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avir At Lindale during CMS and state inspections, most recent first.
A resident with dementia and myelopathy, with moderate cognitive impairment on MDS (BIMS 08), experienced a fall, after which the family raised concerns during a care plan meeting about inaccurate timing of the fall documentation. The facility conducted an investigation, reported the allegation to the State Survey Agency via TULIP, and documented the outcome as inconclusive in its internal provider investigation report. However, review of the TULIP intake showed that no required 5‑day follow‑up/provider investigation report was submitted, and the Administrator acknowledged he had not sent the 5‑day report and was unsure why, despite facility policy requiring submission of a follow‑up investigation report within five business days of the incident.
Two residents were not protected from abuse and neglect when one was physically injured by a CNA during morning care and another was left unattended in the shower by a CNA, contrary to facility policy. Both incidents involved residents with cognitive and physical impairments who required significant assistance, and the failures were confirmed through interviews and documentation.
Three residents with significant physical and cognitive impairments did not receive appropriate incontinent care, as evidenced by one resident being found double briefed and two others reporting similar experiences. Staff interviews and observations confirmed that double briefing occurred, despite facility policy and training prohibiting the practice due to risks of skin breakdown and infection.
A resident with multiple fall risk factors, including Parkinson's disease and moderate cognitive impairment, activated her call light and called for help during a shift change. After not receiving timely assistance, she attempted to get up and fell, resulting in a sprained ankle. The incident was unwitnessed, and staff later confirmed the call light was on when the resident was found. Facility records showed a pattern of unwitnessed falls during night shifts.
Surveyors found that staff failed to follow professional standards for food storage, preparation, and sanitation, including not wearing beard nets, improper cleaning of kitchen equipment, lack of hand hygiene supplies, unlabeled and unsealed food, incomplete temperature and cleaning logs, and inadequate staff training on kitchen sanitation and food safety procedures.
The facility did not provide residents and their representatives with necessary information about filing grievances, including the grievance procedure, access to forms, and details about the grievance officer. Multiple grievances were not followed up or resolved, and there was no system for anonymous submissions, resulting in unresolved concerns.
The facility did not serve palatable or properly tempered food during a reviewed meal, as confirmed by multiple residents and direct observation. Meals were reported and observed to be cold, unappetizing, and missing components such as drinks and desserts, with staff and the RD acknowledging these deficiencies.
The facility failed to provide adequate tracheostomy care for two residents, leading to an Immediate Jeopardy situation. One resident experienced respiratory distress due to an obstructed tracheostomy cannula, resulting in hospitalization and death. Another resident did not receive proper care due to a lack of qualified staff, as the facility relied on a PRN respiratory therapist. These deficiencies placed residents at risk for serious harm.
A long-term care facility failed to maintain an effective infection prevention and control program, with staff not adhering to proper hand hygiene and glove use during resident care. CNAs reused disposable wipes and did not change gloves, while a Treatment Nurse failed to wear PPE and implement enhanced barrier precautions for residents with wounds. Additionally, a suction canister was left unemptied for four days, increasing the risk of bacterial growth.
A resident's dignity was compromised when her urinary catheter drainage bag was repeatedly left uncovered, despite facility policies requiring a privacy cover. The resident, who was cognitively intact, expressed discomfort with the situation. Staff interviews confirmed the responsibility for ensuring privacy covers, highlighting a lapse in maintaining resident dignity.
The facility's kitchen was found to be unsanitary, with unclean dry pantry floors, sticky and greasy containers, and improperly labeled or dated food items. Freezers and coolers were soiled, with improper thawing of meat leading to blood pooling. The deep fryer had a buildup of grease, and serving pans were not air-dried before storage. Staffing issues were noted, with a new dietary manager temporarily managing the kitchen.
A facility failed to implement a baseline care plan for a resident with End Stage Renal Disease, omitting instructions for fluid restrictions as per physician orders. Staff were unaware of the restrictions, and the resident did not know sodas counted as fluids. The facility's policy required baseline care plans to include such instructions, leading to a deficiency in care.
A facility failed to implement and communicate fluid restrictions for a resident with End Stage Renal Disease, leading to the resident consuming more fluids than prescribed. The physician's order for a 1200cc fluid restriction was not initiated or communicated to nursing and dietary departments for eight days. Staff were unaware of the restrictions, and facility records did not reflect them, placing the resident at risk for fluid overload.
A facility failed to ensure proper medication administration for a resident with multiple diagnoses, including End Stage Renal Disease and Diabetes Mellitus. A medication aide left the resident's medications unattended at the bedside, contrary to the facility's policy requiring staff to ensure all medications are consumed. The resident, with moderately impaired cognition, was unaware of who left the medications, highlighting a lapse in pharmaceutical services.
A resident with cognitive deficits and multiple health issues did not receive regular showers on her scheduled days, as reported by the resident and confirmed by facility records. The aide responsible often failed to return to provide care, leading to the resident feeling unclean. The aide was eventually terminated for poor performance, and the facility's policy to ensure scheduled showers was not followed.
The facility failed to protect residents from neglect by not ensuring the availability of emergency medical supplies and adequately trained staff. Two residents with respiratory needs were affected, with one experiencing a cardiorespiratory arrest and a delay in receiving life-saving interventions due to missing equipment and untrained staff.
A resident in a long-term care facility, who was a full code status, experienced a medical emergency and did not receive basic life support due to missing emergency supplies on the crash cart. The resident, who had a tracheostomy, was without oxygen to her brain for about 10 minutes before EMS arrived, resulting in severe brain damage. Interviews revealed a lack of familiarity with the resident's care needs and a failure to ensure emergency supplies were available.
A resident with chronic conditions and existing pressure ulcers did not receive the prescribed wound care, leading to the deterioration of MASD into a necrotic unstageable pressure ulcer. The facility failed to follow its policy for wound assessment and documentation, contributing to the worsening of the resident's condition.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, leading to incomplete documentation of essential healthcare information. The MDS Coordinator's absence contributed to the delay, and the facility's policy mandates timely development of these care plans.
The facility failed to develop and implement comprehensive care plans for two residents. One resident had a discrepancy between the care plan and physician orders regarding code status, while another resident had no care plan completed at all. Staff interviews confirmed the importance of accurate and timely care plans.
A resident with multiple complex medical conditions, including heart failure, diabetes, dementia, and chronic kidney disease, experienced a significant change in condition. The resident refused all oral medications and ordered labs for four days, leading to hospitalization due to urosepsis. Additionally, the resident had decreased oral intake, potentially contributing to dehydration. The facility did not consult with the physician regarding these refusals and decreased intake, resulting in an Immediate Jeopardy situation. This highlights the importance of adhering to protocols for timely communication with medical providers.
A resident with a Foley catheter did not receive appropriate catheter care upon returning from the hospital. There was no order entered for catheter care, and documentation was lacking for an extended period. The resident was later admitted to the hospital with urosepsis and passed away. The facility's policies and procedures for catheter care were not effectively implemented, highlighting potential systemic issues in urinary catheter management.
A resident experienced a 15% weight loss over 26 days due to the facility's failure to monitor his weight and nutritional intake as per the care plan and physician orders. Despite being at high nutritional risk, the resident's weights were not documented, and his oral intake was inconsistently recorded, leading to severe weight loss and hospitalization.
Failure to Submit Required 5‑Day Investigation Report for Alleged Abuse/Neglect Incident
Penalty
Summary
The deficiency involves the facility’s failure to submit a required 5‑day follow‑up investigation report to the State Survey Agency after an allegation related to potential neglect/abuse was reported. A male resident with dementia and myelopathy, who had a quarterly MDS showing a BIMS score of 08 indicating moderate cognitive impairment, experienced a fall. During a subsequent care plan meeting, the resident’s family raised concerns to staff about the inaccuracy of the timing of documentation of the fall. The facility initiated an investigation, and the allegation was reported to the State Survey Agency through TULIP as an intake. The facility’s internal provider investigation report documented that the family’s concerns were addressed and that the investigation outcome was inconclusive. Record review of the TULIP website showed that, for the specific intake number associated with this allegation, no 5‑day report or provider investigation report had been submitted. The Administrator stated in interview that, to his knowledge, he did not send in the 5‑day investigation report for this incident and was unsure what had happened, speculating there may have been an internet outage but providing no confirmation. He acknowledged that the interventions were implemented but the report itself was not turned in to the State Survey Agency. This failure occurred despite a facility policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, which requires the Administrator to provide a follow‑up investigation report within five business days of the incident.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse and neglect. In the first incident, a female resident with a history of stroke, severe cognitive impairment, and significant physical limitations required moderate to maximal assistance with activities of daily living. On the morning of the incident, a CNA, identified as agency staff, assisted the resident with morning care. During the process, the CNA grabbed the resident by the arm, resulting in a skin tear on the resident's left forearm. The resident reported that the aide was being too rough and that she had told the aide to stop. A roommate corroborated that the resident was vocalizing distress and that the aide continued to dress her despite her protests. The facility did not have a personnel file for the agency CNA involved in the incident. In the second incident, another female resident with moderately impaired cognition, limited mobility, and a need for extensive assistance with bathing was left unattended in the shower by a CNA. The CNA left the resident alone to retrieve a towel, during which time the resident remained unsupervised. The CNA later reported that the resident refused care and became physically aggressive, after which the CNA left the facility before the end of her shift. The resident was later assisted out of the shower by another staff member. Facility policy explicitly states that residents requiring shower assistance are never to be left alone during bathing. Both incidents were confirmed through interviews, record reviews, and facility documentation. The facility's own policies require staff to use safe lifting and movement techniques and to remain with residents during bathing. The actions and inactions of the CNAs involved directly resulted in the residents not being protected from abuse and neglect, as required by facility policy and regulatory standards.
Failure to Provide Appropriate Incontinent Care and Maintain Personal Hygiene
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain good personal hygiene, specifically regarding appropriate incontinent care. Three residents were identified as not receiving proper care: one resident was observed wearing two saturated briefs at the same time, a practice known as double briefing, which is not permitted by facility policy. Two other residents reported having been double briefed in the past, although they could not recall specific dates or staff involved. Observations and interviews confirmed that double briefing had occurred, and one resident was found with redness to the buttocks during care. Medical records indicated that the affected residents had significant physical and cognitive impairments, including chronic respiratory failure, heart failure, diabetes, quadriplegia, dementia, and incontinence. Care plans for these residents included interventions such as regular checks for incontinence and prompt changing of disposable briefs. Despite these interventions, staff interviews revealed that double briefing had been practiced, sometimes at the direction of other staff members, and that staff were aware this was not acceptable due to the risk of skin breakdown and infection. Staff interviews further confirmed knowledge of the facility's expectations regarding incontinent care, with several CNAs and an LVN stating that double briefing was not allowed and could lead to skin integrity issues. Documentation showed that at least one CNA had received training indicating not to double brief residents. Facility policies reviewed emphasized the importance of cleanliness, comfort, and prevention of infection and skin irritation, but the observed and reported practices did not align with these standards.
Failure to Respond to Call Light and Supervise Resident Results in Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and a timely response to a call light for a resident with multiple risk factors for falls. The resident, who had diagnoses including Parkinson's disease, ataxia, osteoporosis, and moderate cognitive impairment, was care planned as a fall risk and required moderate assistance with transfers. On the morning of the incident, the resident activated her call light and called for help while sitting on the side of her bed. After waiting without receiving assistance, she attempted to get up on her own and subsequently fell, resulting in a sprained left ankle. The fall was unwitnessed and occurred during a shift change, a period when staffing was affected by a CNA no-show. Multiple staff interviews confirmed that the call light was on when the resident was found on the floor, but staff were unable to determine how long it had been activated. Video footage reviewed by facility leadership and the resident's responsible party showed the resident calling for help and falling after not receiving timely assistance. The facility's incident and accident reports indicated a pattern of unwitnessed falls during the night shift in the weeks surrounding the incident. At the time of the fall, the resident was found on the floor by incoming CNAs, who notified the nurse on duty. The nurse assessed the resident, who initially denied injury, but later complained of ankle pain and was sent to the hospital, where a sprain was diagnosed. The failure to respond promptly to the call light and provide adequate supervision during a known high-risk period directly contributed to the resident's avoidable fall and injury.
Failure to Maintain Food Service Safety and Sanitation Standards
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation practices. Staff were not wearing required beard nets, and several large baking sheets and steam table pans were found with carbon build-up, moisture, water, and food particles inside. The three-compartment sink was filled with dirty pots and pans, and the steam table had food splatter on the glass. Dried blood was found on the floor near a handwashing sink, which lacked soap and paper towels, and the hand sanitizer at the kitchen entrance was empty or broken. Trash and debris were present in multiple areas, and an open package of meat in the refrigerator was unlabeled and not sealed. The refrigerator door was left open with frost buildup, and expired food was found on the counter. Temperature logs for refrigerators and freezers had not been maintained since a specified date, and there was no evidence of dishwasher sanitization testing or cleaning logs for October. The ice machine seal was dirty and not listed on the cleaning log. Interviews revealed that staff had not been in-serviced on kitchen sanitation, serving sizes, or food temperatures, and the dietary manager was absent and had recently quit. Some staff were unsure if all dietary staff had food handler certifications, and one dishwasher reported not being trained on dishwashing or sanitization procedures. The administrator and ADON were unaware of the kitchen's condition, and there was no documentation of staff training on kitchen sanitation. These findings indicate a failure to comply with professional standards for food service safety, potentially placing residents at risk.
Failure to Provide Grievance Information and Follow-Up
Penalty
Summary
The facility failed to provide residents and their representatives with adequate information regarding their rights to file grievances, including the grievance procedure, access to grievance forms, information about the grievance officer, and the process for filing anonymous grievances. During record review, it was found that 9 out of 13 grievances had not been followed up by the grievance officer or administrator. Interviews revealed that the Resident Council President and other staff were aware of grievances that had not received responses, and there was no system in place for submitting grievances anonymously. Grievance forms were only available outside the social worker's office, and the process for handling grievances was not consistently followed. The administrator and social worker (grievance officer) acknowledged that several grievances had not been addressed and that there was a lack of follow-up. The assistant director, who helped residents file grievances, stated she was not informed of the outcomes. The facility's grievance policy required prompt notification and written responses within five working days, but this was not consistently implemented. The lack of proper grievance handling and communication placed residents at risk of having their concerns unresolved.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable, appetizing, and appropriately tempered food for residents during the noon meal on 10/28/2025. Multiple residents and a family member reported dissatisfaction with the food, describing it as cold, unappetizing, overly salty, or lacking in flavor. Observations during meal service confirmed that food items such as spaghetti and garlic bread were served cold or hard, salads were only cool, and drinks were missing from trays. Test trays prepared for surveyors also reflected these issues, with the Registered Dietitian (RD) present and agreeing that the food was not hot, bread was hard, and drinks and desserts were missing from some trays. Interviews with residents revealed consistent complaints about the quality and temperature of the food, with several stating that meals were not enjoyable and sometimes inedible. The Administrator acknowledged the absence of a dietary manager, who had recently resigned, and stated that the facility's policy requires food to be nourishing, palatable, and served at safe temperatures. The facility's own policy on food preparation and service, revised in November 2022, mandates compliance with safe food handling practices, which was not met during the observed meal service.
Failure to Provide Adequate Tracheostomy Care
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents requiring tracheostomy care, leading to significant deficiencies. One resident, a female with a history of cardiac arrest, cerebral infarction, pneumonia, and pulmonary edema, experienced respiratory distress due to an obstructed tracheostomy inner cannula. Despite attempts to suction, the obstruction was not cleared, resulting in the resident's hospitalization and subsequent death. The medical director indicated that standard practice would involve removing the inner cannula to check for obstructions, which was not done in this case. Another resident, a male with acute and chronic respiratory failure and pneumonitis, also did not receive proper tracheostomy care. The facility lacked full-time qualified staff to perform necessary tracheostomy care, relying instead on a respiratory therapist who was only available on a PRN basis. The Director of Nursing stated that nurses were not permitted to remove or change cannulas, which contradicted the expectations set by the Regional Nurse, who indicated that nursing staff should be able to perform such tasks for certain types of tracheostomies. These failures resulted in the identification of an Immediate Jeopardy situation, as the facility did not ensure that residents received care consistent with professional standards. The lack of proper tracheostomy care placed residents at risk for serious harm, impairment, or death, highlighting significant deficiencies in the facility's ability to provide necessary respiratory care and services.
Removal Plan
- Nursing staff will be in-serviced to respond to medical emergencies for residents, when their tracheostomy becomes clogged, a mucus plug is identified, or resident is having difficulty breathing.
- Resident #2 will be provided for appropriately, with having all nurses trained in decannulation/re-cannulation of tracheostomy, in the case of a mucus plug/blockage, by the facility respiratory therapist, or by the Director of Nursing, who will be trained by the facility respiratory therapist.
- The Director of Nursing, Clinical Support Specialist, and VP of Clinical Operations will deliver all following in-service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. Competency with return demonstration will be completed.
- The DON will review new hire orientation packet to ensure these above in-services are completed prior to the first shift on the floor, including tracheostomy competencies including decannulation/re-cannulation emergency procedures.
- Facility policy was updated to reflect decannulation and re-cannulation of tracheostomy is necessary in an emergency situation where the airway is compromised by a mucus plug, and the suction catheter meets resistance.
- Physician orders added to each resident with a tracheostomy, to include, may decannulate and re-cannulate tracheostomy if unable to establish patent airway or mucus plug present, per LVN/RN.
- Resident orders updated to include a tracheostomy one size smaller to be included in emergency supply box at bedside.
- The 24-hour report in the EMR which runs all progress notes in real time, will be monitored daily in the clinical meeting for changes in condition by the clinical team, DON/ADON/MDS.
- The DON or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy decannulation/re-cannulation procedure.
- DON/ADON's will make rounds daily, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress regarding trach status.
- The Director of Nursing and VP of Clinical Operations viewed each resident with a tracheostomy to ensure all emergency supplies were present at bedside.
- An interim QAPI committee meeting was completed.
- IDT will review for compliance monthly in QAPI.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and glove use among staff members. During incontinent care for a resident, CNAs failed to change gloves and perform hand hygiene, and one CNA reused disposable wipes multiple times without folding them, which could lead to cross-contamination. The CNAs admitted to being nervous during the observation, which contributed to their mistakes. In another instance, the Treatment Nurse did not change gloves or perform hand hygiene while performing wound care on two residents. The nurse also failed to wear appropriate personal protective equipment (PPE) during the procedure. Additionally, the facility did not have enhanced barrier precautions (EBP) in place for a resident with a stage 3 pressure ulcer, and the necessary signage was missing from the resident's door. The Treatment Nurse acknowledged the importance of EBP and admitted to oversight in implementing it. The facility also failed to manage a resident's suction canister properly, leaving it unemptied for four days after the resident was discharged to the hospital. This oversight could lead to bacteria build-up and potential infection risks. The Regional Nurse confirmed that suction canisters should be emptied after each use to prevent bacterial growth. These deficiencies highlight significant lapses in infection control practices, potentially putting residents and staff at risk for infection and cross-contamination.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident by not ensuring that her urinary catheter drainage bag was covered with a privacy bag as required. This deficiency was observed on multiple occasions, specifically on three separate days, where the resident's catheter drainage bag was left uncovered and facing the door. The resident, who was cognitively intact and able to communicate effectively, expressed that the lack of privacy cover bothered her. The facility's policy and the resident's care plan both indicated the necessity of a privacy cover for the urinary catheter drainage bag to maintain the resident's dignity. Interviews with facility staff, including a CNA, an LVN, and the Regional Nurse, confirmed that it was the responsibility of the nursing staff to ensure privacy covers were used on urinary catheter drainage bags. The staff acknowledged the importance of these covers for maintaining resident dignity. Despite this, the resident's catheter bag remained uncovered, indicating a lapse in adherence to the facility's policies and procedures regarding resident dignity and privacy.
Unsanitary Kitchen Conditions in LTC Facility
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, which could potentially place residents at risk of foodborne illness. Observations revealed that the dry pantry was unclean, with dried spills, scattered beans, and pieces of paper and cardboard on the floor. Containers on the open wire rack were found to be sticky and greasy, with flour-like, cornmeal-like, and dirt-like substances on their lids and bodies. Additionally, food items in the cooler were not labeled or dated, and some trays contained unknown food products without labels or dates. The facility's freezers and coolers were also found to be in unsanitary conditions. The handles and fronts of the freezers were soiled with food debris and unknown substances, and vents were covered with food and dried liquid splash. In one cooler, a 10 lb. chub of hamburger meat was thawing improperly, with blood seeping out and pooling on the shelf. The deep fryer was noted to have a buildup of grease and floating food detritus, and stainless steel serving pans were stacked wet and greasy, indicating they were not air-dried before storage. Interviews with the dietary manager and administrator revealed that the facility was experiencing staffing issues, with the previous dietary manager having left abruptly and new employees still being trained. The dietary manager from a sister facility was temporarily managing the kitchen and acknowledged the unsanitary conditions, noting that corrective actions were being taken. Facility policies on sanitation and food safety were reviewed, highlighting the need for clean and sanitary food service areas and proper date marking of food items.
Failure to Implement Baseline Care Plan for Fluid Restrictions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with End Stage Renal Disease on hemodialysis. The baseline care plan did not include instructions for managing the resident's fluid restrictions, which were part of the admission physician orders. The resident's medical records, including the Medication Administration Record (MAR) and meal ticket, lacked any indication or instructions for fluid restrictions, leading to a lack of awareness among staff members about the resident's needs. Interviews with the resident and various staff members, including a medication aide, a charge nurse, and dietary staff, revealed that none were aware of the resident's fluid restrictions. The resident himself was unaware that sodas counted towards his fluid intake. The facility's policy on baseline care plans required that such plans include initial goals based on admission orders and dietary instructions, but this was not adhered to in the case of the resident, resulting in a deficiency in providing person-centered care that meets professional standards.
Failure to Implement and Communicate Fluid Restrictions for a Resident
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident #286, who was on fluid restrictions due to End Stage Renal Disease and undergoing hemodialysis. The physician's order for fluid restrictions was not initiated or communicated to the nursing and dietary departments for eight days. The order specified a fluid restriction of 1200cc per day but did not include instructions on how to distribute this amount throughout the day. This lack of communication and clarity in the physician's order led to the resident not receiving the appropriate care to maintain his well-being. Resident #286, a male with moderately impaired cognition, was unaware of his fluid restrictions and continued to consume fluids without limitation. The facility's records, including the Medication Administration Record (MAR) and meal tickets, did not reflect the fluid restrictions, and staff members, including the Medication Aide and Charge Nurse, were not informed of the restrictions. The dietary staff also did not receive any communication regarding the fluid restrictions, resulting in the resident receiving more fluids than prescribed. Interviews with facility staff, including the Vice President of Clinical Operations (VPCO) and Director of Nursing (DON), revealed that the discrepancy between the hospital discharge order and the facility's order was not noticed, and the fluid restrictions were not implemented since the resident's admission. The facility's policy on fluid restrictions was not followed, as the physician's order was not verified, and the distribution of fluids was not communicated to the relevant departments. This oversight placed the resident at risk for fluid overload, which could lead to serious health complications.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided to meet the needs of a resident, specifically by not ensuring that medications were administered as ordered. A medication aide, identified as MA C, left a resident's medications unattended at the bedside. The resident, who had multiple diagnoses including End Stage Renal Disease, Diabetes Mellitus, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, and a cerebrovascular accident, was found with a cup of clear liquid and a small plastic container with 12 pills on an over-the-bed table. The resident, who had a BIMS score indicating moderately impaired cognition, was unaware of who left the medications. During an interview, MA C admitted to leaving the medications at the bedside after watching the resident start taking them, without ensuring all medications were consumed. The Director of Nursing (DON) confirmed that the expectation was for medication aides and nurses to stay with residents until all medications were taken, to prevent the risk of residents not receiving their medications as ordered. The facility's policy on medication administration required medications to be administered as ordered, which was not adhered to in this instance.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to maintain grooming and personal hygiene for a resident who was dependent on staff for activities of daily living. The resident, who had multiple diagnoses including weakness, muscle wasting, and cognitive deficits, reported that she was not receiving regular showers on her scheduled days. She expressed that the aide responsible for her care often did not return to provide the necessary assistance, leaving her feeling unclean. The resident also mentioned that the aide would sometimes attempt to provide care at inappropriate times, such as early in the morning, which she found disruptive. Interviews with facility staff revealed that the aide in question had been restricted from entering the resident's room and was eventually terminated for poor performance, including not changing residents at night. The facility's records showed that the resident received only 14 out of the 18 scheduled showers over a six-week period. The facility had a policy in place to ensure residents received showers as per their request or scheduled protocols, but this was not adhered to in the case of this resident.
Neglect in Emergency Preparedness and Staff Training
Penalty
Summary
The facility failed to protect residents from neglect, specifically in ensuring the availability of necessary emergency medical supplies and adequately trained staff. Two residents, one with acute respiratory failure and morbid obesity, and another with severe cognitive impairment and tracheostomy status, were directly affected by these deficiencies. The facility did not have essential supplies such as AED pads, Ambu bags, and emergency tracheostomy equipment readily available, which are critical for residents with respiratory needs. In one incident, a resident experienced a cardiorespiratory arrest and was without oxygen to the brain for approximately 10 minutes until EMS arrived. The staff was unable to perform adequate emergency care due to the absence of necessary equipment, such as an Ambu bag and AED pads, on the crash cart. Additionally, the staff was not familiar with the resident's care needs, and there was a lack of emergency tracheostomy supplies at the bedside, which contributed to the delay in providing life-saving interventions. The facility also failed to ensure that staff were adequately trained in noninvasive respiratory care and the use of respiratory equipment. Interviews with staff revealed that there was no formal training or competency check-offs for the use of the Trilogy system, which is a noninvasive respiratory support system. This lack of training and preparedness left staff unable to effectively respond to respiratory emergencies, further endangering the residents' health and safety.
Removal Plan
- All nurses will be educated on respiratory therapy for nurses, including but not limited to tracheostomy care, Trilogy care, Tracheostomy suctioning, by the respiratory therapist.
- The VP of Clinical Operations, Clinical Support Specialist, respiratory therapist and ADON will deliver in service education to nurses one on one.
- If emergency items are on back order from the supplier, the facility is able to obtain said supplies from many of our sister facilities. The Director of Nursing, Administrator, ADON, and Treatment Nurse were educated by the VP of Clinical Operations, to notify the VPCO immediately if emergency supplies are back order and are needed by the facility immediately. The VPCO will ensure supplies are obtained from a sister facility.
- Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and on the crash cart, verified by the VP of Clinical Operations.
- Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations.
- Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations.
- There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility. Nurses were in serviced by the VP of Clinical Operations regarding the new emergency toolboxes. All nurses will be in serviced on this new system before they are able to return to facility for their shift. All new nurses will be trained on this practice prior to starting their shift on the floor. This training will be placed in the clinical orientation packet with HR by the VP of Clinical Operations.
- All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart. The 100-hall nurse is designated to check the crash cart every night, this is included on the in-service given to nursing staff by the VP of Clinical Operations. Also included on the in-service was for the nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log. All nurses will be in-serviced on this system prior to returning to their shift. All new nurses will be trained on this practice prior to beginning their shift. This information is added to the clinical orientation with HR by the VP of Clinical Operations.
- All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach are at the bedside of tracheostomy residents.
Failure to Provide Basic Life Support Due to Missing Emergency Supplies
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, who was a full code status, experienced a medical emergency where she turned blue and had no pulse or heart rate. When the facility staff requested the crash cart, it was found that essential emergency supplies, such as AED pads and an ambu bag, were missing. This deficiency in emergency preparedness led to a delay in providing the necessary life-saving interventions. The resident, who had a tracheostomy and was at risk for respiratory complications, did not have the required emergency equipment at her bedside as ordered by the physician. The facility nurses were only able to perform chest compressions without the aid of an ambu bag or AED pads. The resident was without oxygen to her brain for approximately 10 minutes before EMS arrived, resulting in severe brain damage and her subsequent placement on hospice care. Interviews with facility staff revealed that there was a lack of familiarity with the resident's care needs and a failure to ensure that emergency supplies were available and accessible. The crash cart had not been properly checked and stocked, as evidenced by missing check-offs on the crash cart checklist. Staff members reported that they were informed by the former DON that the necessary supplies were on back order, which contributed to the unavailability of critical emergency equipment during the incident.
Removal Plan
- All nurses will be educated on the crash cart policy and where to find emergency medical equipment to perform CPR.
- All equipment required, including but not limited to, Ambu bag, AED, AED pads, and emergency tracheostomy cannulas, will be available for use in the facility, and at the bedside of tracheostomy residents, and on the crash cart.
- The VP of Clinical Operations, Clinical Support Specialist, and ADON will deliver in-service education to nurses one on one.
- Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and on the crash cart, verified by the VP of Clinical Operations.
- Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations.
- Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations.
- There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility.
- Nurses were in-serviced by the VP of Clinical Operations regarding the new emergency toolboxes.
- All nurses will be in-serviced on this new system before they are able to return to facility for their shift.
- All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart.
- Nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log.
- All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach care at the bedside of tracheostomy residents.
- The facility respiratory therapist educated all nurses on the use of the Ambu bag in case of respiratory distress during the on-site training.
- All nurses will be in-serviced on this policy before they return to facility for their next shift by the facility respiratory therapist or RN trained by the facility respiratory therapist before beginning their next shift.
- All nurses on staff at this time besides one that is in the hospital, have been in-serviced by the VP of Clinical Operations.
- All new nurses will be educated on the policy for crash cart and emergency tracheostomy supply boxes prior to starting their shift.
- This information will be included in the orientation packet.
- Will review for compliance in QAPI.
- The DON/designee will monitor daily to ensure all items are present on crash cart and the nurse who checked the crash cart initials are on the crash cart log.
- Nurses call the DON with any missing items.
Failure to Prevent Pressure Ulcer Deterioration
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and deterioration of pressure injuries for a resident. The resident, who was readmitted with chronic conditions such as chronic kidney disease, diabetes, hypertension, and congestive heart failure, was at risk for developing pressure ulcers. Upon admission, the resident had one stage 3 pressure ulcer and two unstageable pressure ulcers. Despite having orders for wound care to be performed twice daily, the resident did not receive 6 out of 10 scheduled treatments for MASD on the bilateral buttocks, leading to the deterioration of the condition into a necrotic unstageable pressure ulcer. The facility also failed to follow its policy by not assessing the resident's deteriorating wound. The care plan required monitoring and documenting the location, size, and treatment of skin injuries, and reporting any abnormalities to the physician. However, the facility did not have a system in place to ensure that treatments and assessments were performed as ordered and per policy. The wound care doctor noted that several factors, including incontinent care not being performed timely, lack of turning and repositioning, and decreased nutrition, could have contributed to the deterioration of the resident's wound. The facility's documentation of wound treatments policy required accurate documentation of wound assessments and treatments, including response to treatment and changes in condition. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for the resident's wound care on specific dates. This failure resulted in the identification of an Immediate Jeopardy situation, indicating a serious threat to the health and safety of the resident.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is necessary to provide effective and person-centered care. Resident #1, a male with diagnoses including heart failure, muscle weakness, diabetes, hypertension, and difficulty walking, did not have a completed baseline care plan. The sections for activities of daily living, fall/safety/restraints/alarms, nutrition, pain, skin, sensory needs, elimination, infection, anticoagulant therapy, treatment(s)/procedures, and physician orders were not filled out, and the care plan was neither locked nor signed. Resident #2, a female with diagnoses including dementia, weakness, atrial fibrillation, chronic obstructive pulmonary disease, and hypertension, also did not have a baseline or comprehensive care plan. The Director of Nursing (DON) confirmed the absence of the care plan and acknowledged that the facility had an action plan to address this issue. The MDS Coordinator, who was responsible for initiating the baseline care plans, had been on vacation, contributing to the delay. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including essential healthcare information such as initial goals, physician orders, dietary orders, therapy services, and PASARR recommendations if applicable.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For Resident #1, the care plan indicated a full code status, while the physician orders and an Out-Of-Hospital Do-Not-Resuscitate Order indicated a DNR status. This discrepancy could lead to confusion among staff regarding the resident's wishes in the event of an emergency. Interviews with LVN A, MDS Coordinator B, and the DON confirmed that the code status in the care plan should match the physician orders to ensure proper care during critical situations. For Resident #2, the facility did not complete a care plan at all. The resident, who had diagnoses including dementia, weakness, atrial fibrillation, chronic obstructive pulmonary disease, and hypertension, was admitted to the facility, but no care plan was developed from the time of admission until the time of the survey. This lack of a care plan could result in the resident's needs not being met. Interviews with facility staff confirmed that comprehensive care plans should be completed within 7-14 days of admission to ensure that all resident needs are identified and addressed.
Failure to Notify Physician of Resident's Condition Changes
Penalty
Summary
The facility failed to consult with the physician when Resident #1 experienced a change in condition, specifically when he refused all oral medications for four days leading up to his hospitalization due to urosepsis. Additionally, the facility did not notify the physician when Resident #1 refused to have ordered labs obtained, which could have identified an underlying urinary tract infection. There was also a failure to inform the physician when Resident #1 had decreased oral intake in the days preceding his hospitalization, potentially contributing to dehydration and subsequent health complications. These failures resulted in the identification of an Immediate Jeopardy situation, highlighting the risks posed to residents by delays in medical treatment and potential health decline. Resident #1, a [AGE] year old with multiple complex medical conditions including heart failure, diabetes, dementia, and chronic kidney disease, was admitted to the facility with a history of joint replacement surgery and other comorbidities. Despite his severe cognitive impairment and dependency on staff for various activities of daily living, the facility did not appropriately communicate his refusal of medications, labs, and decreased oral intake to the physician. This lack of communication and action could have potentially led to a delay in necessary medical interventions and contributed to his deteriorating health status. The facility's policies and procedures clearly outlined the importance of promptly informing the resident, consulting with the resident's physician, and altering treatment when necessary in cases of significant changes in a resident's condition. However, the staff members, including nurses and medical assistants, failed to adhere to these protocols by not notifying the physician of Resident #1's refusals and decreased intake. The lack of communication and documentation regarding these critical issues ultimately resulted in an Immediate Jeopardy situation being identified, highlighting the serious implications of the facility's failures in resident care and communication with medical providers.
Deficiency in Foley Catheter Care Leading to Urosepsis
Penalty
Summary
The facility failed to ensure appropriate care for a resident (Resident #1) with a Foley catheter, leading to a deficiency in preventing urinary tract infections and pain. Upon returning from the hospital with a Foley catheter on 1/1/24, there was no order entered for catheter care, and documentation of catheter care was lacking from 1/1/24 to 1/17/24. Despite having the catheter in place, Resident #1 did not receive the necessary care during this period. The facility also did not clearly document the discontinuation of the Foley catheter or the circumstances surrounding it. The deficiencies in care were highlighted when Resident #1 was admitted to the hospital on 1/22/24 and diagnosed with urosepsis, ultimately leading to the resident's passing on the same day. The lack of appropriate catheter care and documentation not only put Resident #1 at risk of urinary tract infections and sepsis but also resulted in tragic consequences. The facility's failure to ensure catheter care for Resident #1, despite the presence of the Foley catheter, raised concerns about the overall quality of care provided to residents with indwelling catheters. The facility's policies and procedures regarding catheter care were not effectively implemented in Resident #1's case. The absence of documented catheter care, inadequate order entry for catheter care, and lack of clarity on catheter discontinuation all contributed to the deficiency identified during the survey. The failure to provide essential care for residents with indwelling catheters not only posed immediate risks to Resident #1 but also highlighted potential systemic issues within the facility's approach to urinary catheter management.
Failure to Monitor Nutritional Status
Penalty
Summary
The facility failed to provide care that would ensure acceptable parameters of nutritional status for a resident, resulting in a significant weight loss of 15% over 26 days. The resident, an 87-year-old male with multiple diagnoses including dementia, diabetes, and chronic kidney disease, was not appropriately monitored for weight during his stay. Despite having physician orders for daily weights and nutritional supplements, there were no documented weights for the resident from the time of admission until his hospitalization. Additionally, there was a lack of documentation regarding the resident's oral intake for most of his stay, with only sporadic notes indicating fair fluid intake and a significant decline in the days leading up to his hospitalization. The resident's care plan indicated he was at risk for dehydration and malnutrition, with interventions including a mechanical soft diet and vitamin supplements. However, the facility did not follow through with the prescribed daily weights or adequately monitor his nutritional intake. Interviews with staff revealed inconsistencies in the understanding and execution of weight monitoring protocols. The resident's significant other and family member also noted irregularities in the resident's care, including infrequent weighing and inconsistent assistance with meals. The resident's condition deteriorated significantly, leading to hospitalization where he was found to be cachectic and diagnosed with sepsis and encephalopathy. The facility's failure to monitor the resident's weight and nutritional intake as per the care plan and physician orders contributed to this decline. Interviews with various staff members, including the DON, CNAs, and LVNs, highlighted a lack of communication and adherence to protocols, ultimately resulting in the resident's severe weight loss and subsequent hospitalization.
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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