Briarcliff Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Carthage, Texas.
- Location
- 4054 Northwest Loop, Carthage, Texas 75633
- CMS Provider Number
- 676051
- Inspections on file
- 28
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Briarcliff Skilled Nursing Facility during CMS and state inspections, most recent first.
A facility failed to prevent accidents and provide adequate supervision, resulting in one resident with severe cognitive impairment assaulting another resident and a separate incident where a resident at high risk for falls was left on the floor for several hours after falling. Both incidents involved lapses in staff monitoring and supervision, leading to resident injuries and distress.
A resident with cognitive impairment and Parkinson's disease suffered second-degree burns after spilling hot coffee served at an unsafe temperature. The facility lacked policies for monitoring hot liquid temperatures and did not conduct risk assessments for residents. Staff interviews revealed inadequate training and awareness regarding the safe serving of hot beverages, contributing to the incident.
The facility's kitchen failed to meet food service safety standards due to inadequate cleaning and maintenance. Observations revealed black carbon buildup on baking sheet pans and the stove top. Staff interviews indicated infrequent cleaning and a lack of clear responsibilities. The Dietary Manager acknowledged the issue, citing short staffing as a challenge. Maintenance records were incomplete, and the facility lacked a specific cleaning policy, leading to potential risks of foodborne illness and contamination.
The facility failed to maintain a system for the receipt and disposition of controlled drugs, risking medication loss and diversion. Controlled medications were stored in the DON's office without proper logging until destruction, contrary to policy. The Administrator was unaware of the narcotic medication policy, and the last medication destruction was not recent, indicating a lack of regular reconciliation.
A resident was found with unauthorized medications in her room, and two nurses left medication carts unlocked and unattended, violating facility policies. The resident had no order to self-administer, and the carts' unsecured state posed risks of unauthorized access and medication errors.
A facility failed to provide palatable and appetizing food at safe temperatures, affecting four residents. Complaints included bland, cold, and unsuitable food for dietary needs. Despite offering alternatives, dissatisfaction persisted. Staff interviews confirmed frequent resident complaints, and test tray evaluations revealed issues with food quality. The facility's policy on food temperatures was not effectively implemented.
A long-term care facility was found deficient in its infection prevention and control program. Staff failed to perform proper hand hygiene during wound care, used ineffective disinfectants for C. diff, and did not apply enhanced barrier precautions during medication administration and tracheostomy care. These lapses increased the risk of cross-contamination and infection spread among residents.
A resident with severe cognitive impairment and multiple diagnoses was found to be using a lap harness on a Broda chair without proper assessment, monitoring, or documentation as a restraint. Facility staff did not have a clear understanding of the harnesses' use, and there was no physician order or signed consent. Despite justifications for safety and mobility, the lack of documentation and policy on restraints led to a deficiency.
Two residents' MDS assessments failed to accurately reflect the use of restraints. One resident's safety vest and lap belt were not documented as restraints despite being used for positioning due to cerebral palsy. Another resident's limb restraint was not recorded, although it was used for safe positioning due to Rett's Syndrome. Staff and medical professionals considered these devices necessary for safety, but the facility's policy requires accurate assessments to ensure proper care.
A resident with COPD was consistently receiving oxygen at a higher rate than prescribed, contrary to physician orders. Observations showed the resident receiving 3.5 l/min instead of the ordered 2 l/min, and at one point, the setting was at 4 l/min. The LVN and DON confirmed the discrepancy, noting the electronic MAR did not prompt checks for as-needed oxygen settings. The facility's policy requires verification and documentation of oxygen flow rates, which was not followed.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance to prevent accidents for three residents. In one incident, a male resident with severe cognitive impairment and a history of wandering and behavioral issues entered another resident's room in the memory care unit while unsupervised. He assaulted a female resident, causing multiple bruises to her face and forearm, and also struck a nurse with a plunger and a stethoscope. The incident occurred after a CNA left the unit to seek additional staff assistance, leaving the area unsupervised. The assaulted resident was found crying and distressed, with visible injuries, and required transport to the emergency room for evaluation. Documentation and interviews confirmed that the aggressive resident had not previously exhibited such behavior, but the lack of supervision allowed the incident to occur. In a separate event, another male resident with moderate cognitive impairment and a high risk for falls was left unsupervised for several hours during the night. The resident fell at midnight while attempting to walk unassisted and remained on the floor until nearly 5:00 AM before being discovered by staff. Video evidence showed that no staff checked on him during this period, despite care plans indicating he required assistance with mobility and regular checks. The resident sustained bruising and an abrasion as a result of the fall. Staff interviews revealed that the assigned CNA became overwhelmed with other resident care tasks and failed to check on the resident, while the nurse on duty did not verify the resident's status during the night. Both incidents demonstrate a failure to provide adequate supervision and assistance as required by the residents' care plans and assessments. The lack of timely staff intervention and monitoring directly resulted in resident injuries and distress. The facility's inaction in maintaining appropriate supervision and assistance for residents with known risks contributed to these deficiencies.
Failure to Ensure Safe Serving of Hot Coffee Leads to Resident Burns
Penalty
Summary
The facility failed to ensure an environment free from accident hazards, specifically regarding the serving of hot coffee, which resulted in a resident suffering second-degree burns. The resident, who had a history of chronic obstructive pulmonary disease, Parkinson's disease, and cognitive impairment, was served coffee at a temperature that was not monitored for safety. Despite being advised to wait for the coffee to cool, the resident attempted to drink it and spilled it, causing burns to her thighs and groin area. The facility did not have measures in place to prevent such incidents, as there was no policy for monitoring the temperature of hot liquids before serving them to residents. Additionally, the facility did not conduct hot liquid risk assessments for residents, which could have identified those at risk for burns from hot beverages. The dietary manager confirmed that coffee temperatures were not logged, and there was no policy requiring such logs, despite the potential risk to residents. Interviews with staff revealed a lack of awareness and training regarding the safe serving of hot beverages. The staff did not consistently use cups with lids for residents who might be at risk of spilling hot liquids. The facility's failure to implement adequate safety measures and staff training contributed to the incident, highlighting a significant oversight in ensuring resident safety from hot liquid burns.
Deficiency in Kitchen Cleaning and Maintenance
Penalty
Summary
The facility failed to maintain food service safety standards in its kitchen, as observed during a survey. Approximately six baking sheet pans were found with thick black carbon buildup on their rims, and the stove top was also covered with black carbon buildup. These conditions were noted during initial kitchen observations and subsequent rounds. Interviews with kitchen staff revealed that the cleaning of these items was not performed regularly, with one staff member admitting to cleaning the stove top only once a month. The Dietary Manager acknowledged the presence of carbon buildup and stated that deep cleaning of the stove was conducted monthly, but the kitchen was short-staffed, affecting the completion of cleaning tasks. Interviews with various staff members, including the Nutritional Aide and Maintenance Supervisor, highlighted a lack of clarity regarding responsibilities for cleaning and maintenance. The Maintenance Supervisor mentioned that the stove had been serviced months prior, but no maintenance records were available to confirm this. The Dietary Manager and other staff members expressed concerns about the potential fire hazard posed by the carbon buildup, but there was no specific policy or cleaning schedule in place to address these issues. The Corporate Regional Dietician also noted the absence of a specific policy for equipment cleaning and suggested that some pans could be replaced. A review of facility records showed that the Cooks Daily/Weekly Duties checklist required daily cleaning of ovens, but this was not consistently followed. The U.S. Food and Drug Administration Code mandates that food-contact surfaces of cooking and baking equipment be cleaned at least every 24 hours, a standard that was not met by the facility. The lack of adherence to these guidelines and the absence of proper maintenance records contributed to the deficiency in food service safety, potentially placing residents at risk of foodborne illness and contamination.
Failure to Maintain Accurate Records for Controlled Drugs
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records. During an observation and interview, it was found that the controlled medications awaiting disposal were stored in the Director of Nursing's (DON) office behind a double-locked door, with the DON being the only person with access to the keys. The DON's process involved checking the narcotic medication count with a nurse and placing the medications in a basket in the closet without logging them until the pharmacist arrived for drug destruction. This practice did not align with the facility's policy, which requires a controlled medication disposition log to be maintained for documentation purposes. The facility's policy on the disposal of medications, including controlled substances, mandates special handling, storage, disposal, and record-keeping in accordance with federal and state laws. However, the Administrator was unaware of the facility's narcotic medication policy or procedure and could not confirm if the policy was effective in preventing medication diversion. The last medication destruction was recorded on a previous date, indicating a lack of regular reconciliation and documentation of controlled substances awaiting disposal. This deficiency could potentially place residents at risk for loss of prescribed medications, compromise their safety, and lead to drug diversion.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had medications stored in her room without an order to self-administer. The resident, who had a BIMS score indicating intact cognition, was found with a bottle of Geri Lanta on her bedside table and later in her nightstand drawer. The resident stated that she preferred to have the medication accessible for self-administration, but acknowledged that no assessment had been completed to authorize this. Additionally, a medicine cup with an unknown white powder was found in her room, which the resident could not identify. The facility also failed to secure medication carts properly, as observed with two separate nurse's carts. On one occasion, a nurse left the Hall A cart unlocked and unattended, allowing unauthorized access. The nurse admitted to forgetting to lock the cart after retrieving an item. Similarly, another nurse left the Hall B cart unlocked while attending to a resident's blood sugar check, attributing the oversight to nervousness due to the presence of a state surveyor. Both nurses acknowledged the importance of keeping the carts locked to prevent unauthorized access and potential medication errors. Interviews with the ADON, DON, and the Administrator confirmed that the facility's policy required medication carts to be locked when unattended and medications not to be left at residents' bedsides. The staff members involved were aware of these policies but failed to adhere to them, resulting in the potential for medication errors and unauthorized access. The facility's policy emphasized that only authorized personnel should have access to medications, and all staff were trained to ensure medications were not left at bedsides.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed in four residents who were reviewed for palatable food. The residents expressed dissatisfaction with the quality and temperature of the food, with some reporting that the food was bland, cold, or not suitable for their dietary needs. The Dietary Manager and state surveyors also noted that the food sampled during a test tray was not appetizing, with issues such as bland vegetables and overly salty pureed pork chop. Resident #1, a cognitively intact female with peripheral vascular disease and muscle weakness, reported that the food was not good and portions had been cut back. Resident #57, who has Alzheimer's disease and other health conditions, stated that the food was terrible and not suitable for residents with dental issues. Resident #58, who has multiple sclerosis and paraplegia, mentioned that the quality of food had declined significantly in recent weeks. Resident #64, with essential hypertension and other diagnoses, expressed that the food was not good, particularly the supper meals. Interviews with staff members, including CNAs, LVNs, and the Dietary Manager, revealed that residents frequently complained about the food being cold, lacking taste, and not meeting their preferences. Despite the facility's efforts to offer alternative meals and accommodate residents' preferences, the complaints persisted. The facility's policy on food temperatures was not effectively implemented, as evidenced by the lack of regular test tray evaluations and the failure to address residents' concerns adequately.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies observed by surveyors. One significant issue was the failure of a Licensed Vocational Nurse (LVN) to perform proper hand hygiene during wound care for a resident. The LVN did not change gloves or sanitize hands after cleaning a wound and before applying a clean dressing, which could introduce germs into the wound. This oversight was acknowledged by the LVN, who attributed the lapse to nervousness during observation. Another deficiency involved the improper use of disinfectant in a resident's isolation room, which was supposed to be cleaned with a product effective against Clostridium difficile. The facility used a disinfectant that did not kill C. diff spores, potentially allowing the bacteria to spread. The housekeeping staff and infection preventionist were unaware of the disinfectant's ineffectiveness until informed by surveyors, highlighting a gap in the facility's infection control practices. Additional issues included staff failing to perform hand hygiene between feeding two residents, not applying enhanced barrier precautions when administering medications via gastrostomy tube or intravenous line, and not using proper personal protective equipment during tracheostomy care. These lapses in infection control practices placed residents at risk for cross-contamination and infection spread, as staff did not adhere to established protocols for hand hygiene and protective equipment use.
Failure to Properly Assess and Document Use of Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically a lap harness on a Broda chair, which was used for purposes of convenience rather than medical necessity. The resident, who was severely cognitively impaired and had multiple diagnoses including Rett's syndrome, epilepsy, and anxiety disorder, was observed multiple times with leg harnesses attached to the Broda chair. These harnesses were not documented as restraints in the resident's care plan, and there was no physician order or signed consent for their use. Interviews with facility staff, including LVNs, CNAs, the ADON, and the DON, revealed a lack of understanding and documentation regarding the use of the leg harnesses. Staff members consistently stated that the harnesses were used to prevent the resident from falling out of the chair due to her condition, but they did not consider them restraints. However, it was noted that the resident could not remove the harnesses independently, indicating that they functioned as restraints. The facility also lacked a policy on restraints, further complicating the situation. Additional documentation from the resident's MD and PASRR Habilitation Coordinator suggested that the harnesses were necessary for the resident's safety and mobility, allowing her to participate in activities and interact with her community. Despite these justifications, the lack of proper assessment, monitoring, and documentation of the harnesses as restraints constituted a deficiency in the facility's care practices.
Inaccurate MDS Assessments for Restraints
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding the use of restraints. For Resident #2, the quarterly MDS assessment did not accurately reflect the use of a safety vest (trunk harness) or lap belt as a restraint. Despite the care plan indicating the use of these devices for positioning and safety due to the resident's profound intellectual disabilities and cerebral palsy, the MDS assessment did not list them as restraints. Observations showed Resident #2 using a trunk harness and lap belt, which restricted forward motion, but staff and medical statements indicated these devices were necessary for mobility and did not restrict freedom of movement. Similarly, for Resident #5, the quarterly MDS assessment failed to indicate the use of a limb restraint. The care plan noted the need for a lap harness for safe positioning due to the resident's Rett's Syndrome and epilepsy, but there was no order or consent for the harness. Observations confirmed the use of leg harnesses, and staff interviews revealed that the harness was used to prevent the resident from falling out of the chair. Despite this, the harness was not documented as a restraint in the MDS assessment. The facility's policy requires accurate assessments to develop a comprehensive care plan, but the inaccuracies in the MDS assessments for both residents could lead to a lack of appropriate care and services. The RAI manual defines restraints as devices that restrict movement and cannot be easily removed by the resident, which was applicable in these cases. However, the facility staff and medical professionals viewed the devices as necessary safety measures rather than restraints.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions. The resident, who was cognitively intact and required assistance with daily activities, had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. However, observations over several days revealed that the resident was consistently receiving oxygen at 3.5 liters per minute, and at one point, the oxygen concentrator was set at 4 liters per minute. This discrepancy was not documented in the medication administration record, indicating a failure to administer oxygen as ordered. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the oxygen settings were not in compliance with the physician's orders. The LVN acknowledged that the electronic medication administration record did not prompt checks for the oxygen settings since it was prescribed on an as-needed basis. Both the DON and the facility Administrator emphasized the responsibility of nursing staff to ensure that oxygen is set at the prescribed rate. The facility's policy on applying oxygen delivery devices requires staff to verify the flow rate and document the procedure, which was not adhered to in this case.
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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