Capstone Healthcare Of Daingerfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Daingerfield, Texas.
- Location
- 507 E W M Watson Blvd, Daingerfield, Texas 75638
- CMS Provider Number
- 675755
- Inspections on file
- 31
- Latest survey
- April 24, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Capstone Healthcare Of Daingerfield during CMS and state inspections, most recent first.
The facility did not update or post daily nurse staffing information for several consecutive days, leaving outdated information visible at the nurse's station. Staff interviews indicated that the night shift nurse was responsible for this task, but it was not completed due to a temporary nurse working at night. The DON and ADON confirmed the lapse and acknowledged that the daily posting was not maintained as required by facility policy.
The facility did not conduct or document a comprehensive facility-wide assessment to determine necessary resources for competent care, resulting in frequent CNA shortages and unmet staffing levels as outlined in its own assessment. Staff and residents reported delays in care, missed showers, and inadequate assistance, with management often unable to fill staffing gaps or provide support. Time sheets confirmed that staffing levels were consistently below required numbers, directly impacting resident care.
Staff failed to maintain the privacy and confidentiality of resident medical records by leaving electronic medical records open and visible on unattended medication carts during medication administration. Both a nurse and a medication aide left sensitive information accessible to others in the hallway, in violation of facility policy and HIPAA regulations.
Surveyors found that the facility did not develop or implement complete, person-centered care plans for three residents. One resident's care plan omitted her use of a vape and smoking, despite staff awareness and her need for supervision. Another resident's care plan failed to address her use of clozapine and her PASRR-identified serious mental illness and intellectual disability. A third resident's care plan did not mention her placement in the memory care unit, even though she had dementia and related diagnoses. These omissions were confirmed by the MDS Coordinator and DON, who cited recent organizational changes as a contributing factor.
A resident with a gastrostomy tube received enteral nutrition without a physician's order specifying the type of feeding formula. Staff and administration confirmed that the order lacked this critical detail, and facility policy required such specificity. The omission was identified through observation, record review, and interviews, with staff acknowledging the risk of administering the wrong formula.
Licensed staff, including nurses and medication aides, administered antihypertensive medications to residents outside of physician-ordered blood pressure parameters, despite clear instructions to hold the medication when readings were too low. Several residents with complex medical conditions received these medications inappropriately, and interviews with staff and administration revealed that competency checks had not been completed or documented as required. Facility policies and assessments called for regular evaluation of staff competency, but these were not followed, resulting in improper medication administration.
Staff administered metoprolol to three residents even when their blood pressure readings were below physician-ordered parameters, as documented in the MAR and confirmed by interviews with nursing staff and facility leadership. This failure to follow medication hold parameters was observed on multiple occasions and involved both nurses and medication aides.
Surveyors found that drugs and biologicals were not properly labeled or secured, including instances where a resident had non-ordered medications at bedside, a lock box with controlled substances was not affixed in the medication room refrigerator, another resident's prescription cream was left unsecured, and medication carts were left unlocked and unattended by staff. These actions were contrary to facility policy and professional standards.
Surveyors found that the facility did not consistently provide meals that were palatable, attractive, or served at an appetizing temperature. Multiple residents reported dissatisfaction with the taste and temperature of the food, and surveyors confirmed that some meal items were bland and not hot. The Dietary Manager tasted foods infrequently and relied on staff to follow recipes, with limited recent training. No policy on recipe adherence was provided during the survey.
Surveyors identified failures in food labeling, dating, and discarding expired items in the kitchen and storage areas, as well as a CNA not sanitizing hands between passing meal trays. The Dietary Manager and Administrator confirmed that all food items should be properly labeled and dated, and that staff are expected to follow hand hygiene protocols, but these procedures were not consistently followed as observed and confirmed in staff interviews and policy reviews.
The facility did not ensure that required HIV and restraint training was completed for several staff members, including the Administrator, DON, ADON, and two LVNs, due to lapses in assignment and monitoring of trainings following a change in ownership. Documentation of training completion and hire dates was missing, and interviews confirmed that not all staff received the necessary education as required.
A resident with severe cognitive impairment and an indwelling catheter did not have her Foley catheter drainage bag covered as required by physician order and facility policy, resulting in the bag being visible to others on multiple occasions. Staff interviews confirmed awareness of the privacy and dignity issue, and the facility's policies emphasized the importance of keeping catheter bags covered.
A resident with left-sided hemiplegia, diabetic neuropathy, and anxiety was found in bed with her call light out of reach, requiring assistance from a surveyor to access it. Staff interviews confirmed uncertainty about why the call light was not accessible, despite facility policy requiring call lights to be within reach. The resident was cognitively intact and dependent on staff for daily activities, and the failure to provide the call light within reach was not in accordance with facility policy.
A resident with intact cognition and multiple medical conditions was not provided showers as requested, receiving bed baths instead on several occasions. Staff and administration acknowledged the resident's right to choose her bathing method, but staffing issues led to her preferences not being honored, contrary to facility policy supporting resident self-determination.
A resident with severe cognitive impairment and multiple medical conditions had a signed OOHDNR order, but the code status in the EMR and on the resident's door was not updated to reflect this change. Staff interviews revealed confusion over responsibility for updating code status, and facility policy requiring prompt documentation of advance directives was not followed, resulting in the resident's wishes not being properly recorded.
A resident with multiple medical conditions, including hemiplegia and diabetes, was found to have a broken, jagged light cover in her room that remained unrepaired for several weeks despite staff awareness and an open work order. Staff, including the Maintenance Director, LVN, DON, and Administrator, acknowledged the issue and its potential to cause injury, but the repair was not completed, resulting in a failure to maintain a safe and comfortable environment.
Two residents with chronic health conditions reported missing clothing items over several months, repeatedly raising the issue in meetings and to staff. Despite these reports, no formal grievances were filed, and the facility did not promptly investigate or resolve the complaints as required by policy.
Two residents who required assistance with ADLs did not receive scheduled showers due to inconsistent staff assignments and incomplete documentation. When the shower aide was reassigned, other aides did not consistently provide showers, resulting in missed care and residents expressing dissatisfaction with their hygiene. Facility leadership confirmed that showers were not provided as scheduled, contrary to care plans and facility policy.
A resident with a right-hand contracture did not consistently receive a prescribed splint to maintain range of motion, as required by physician orders and the care plan. Observations showed the splint was not in place, and there was no documentation of refusal, despite staff stating the resident sometimes declined due to tenderness. Nursing staff marked the MAR as completed without verifying application, and the care plan was not updated to reflect refusals, resulting in a failure to provide appropriate ROM interventions.
A resident with multiple medical conditions was found keeping a vape device at her bedside without documentation of an assessment for safe use or inclusion in her care plan. Staff interviews revealed confusion about policies regarding vape storage and use, and the facility's policy requiring assessment and documentation for e-cigarette use was not followed.
A resident with severe cognitive impairment and an indwelling foley catheter was found to have the catheter unsecured to her leg, despite care plan interventions and physician orders requiring a securement device. Staff interviews confirmed the absence of the securement and acknowledged responsibility for ensuring proper catheter care, in line with facility policy.
Two residents requiring respiratory care did not receive care consistent with professional standards: one received oxygen at a higher flow rate than prescribed, and another's nasal cannula was repeatedly found improperly stored outside of a bag, contrary to staff expectations for infection control. Staff interviews revealed inconsistent monitoring and lack of recent training on oxygen equipment use and storage.
A resident with severe cognitive impairment and a history of PTSD and anxiety did not receive a trauma assessment or have PTSD addressed in the care plan, despite facility policy and staff acknowledgment that such assessments are required on admission. Staff interviews confirmed the omission and recognized its importance for providing trauma-informed care.
A medication aide failed to document the administration of a controlled pain medication on the narcotic record immediately after giving it to a resident with multiple chronic conditions. This omission was observed during a survey, and both the DON and Administrator confirmed that facility policy requires immediate documentation to ensure accurate reconciliation of controlled substances.
A resident with multiple medical conditions, including hemiplegia and diabetes, was observed using a vape device, but her care plan did not address her tobacco use and no safe smoking evaluation was documented. Staff interviews revealed confusion about who was responsible for completing smoking assessments, and the required quarterly evaluations were not completed as outlined in facility policy.
A resident in a LTC facility exhibited escalating aggressive behaviors, including kicking and attempting to choke other residents. Despite being aware of these behaviors, the facility staff failed to implement effective measures to prevent harm, such as notifying the physician or providing one-to-one monitoring. This inaction led to an Immediate Jeopardy situation, as the facility did not ensure the safety and protection of its residents from abuse.
A resident with severe cognitive impairment and aggressive behaviors was inadequately supervised, leading to an altercation where he attempted to choke another resident. Despite multiple reports of escalating behaviors, the facility failed to implement effective interventions or notify the physician, resulting in a serious safety breach.
A resident kicked another resident's feet in a wheelchair, but the incident was not reported to the administrator or HHSC as required. The resident had a history of severe cognitive impairment and exhibited wandering and aggressive behaviors. Staff failed to complete an incident report or notify authorities, citing a change of shift. Interviews revealed a lack of consensus on whether the behaviors were escalated, and the facility's policy on reporting altercations was not followed.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the current date, resident census, and actual staff hours worked at the beginning of each shift, from 04/20/2025 to 04/24/2025. During an observation, the posted staffing information was found to be outdated, displaying the date 04/19/2025. Interviews with staff revealed that the night shift nurse was responsible for updating the staffing information, but this was not completed for several days, reportedly due to a temporary nurse working at night. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both acknowledged that the daily posting was not maintained as required and that it is typically checked by the ADON. Record review confirmed that the facility's policy requires daily posting of direct care staffing numbers for every shift. Attempts to interview the night shift nurses responsible for the posting were unsuccessful. The lack of updated staffing information could affect residents, their families, and visitors by limiting access to current information about staffing levels and census, as noted in the report.
Failure to Conduct and Implement Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure daily staffing needs were met according to its own facility assessment. Multiple staff members and residents reported frequent CNA shortages, especially during evening and night shifts, resulting in delayed responses to call lights, missed showers, and residents receiving bed baths instead. Staff consistently indicated that management was aware of the staffing shortages but did not consistently provide adequate coverage or assistance. Record reviews of time sheets showed that the number of CNAs working various shifts was consistently below the levels outlined in the facility's own assessment. On several occasions, only one or two CNAs were present for entire shifts when the assessment called for significantly more. Staff interviews confirmed that when CNAs called off or did not show up, their positions were often not filled, and management rarely assisted in covering these gaps. The use of agency staff was only recently implemented, and prior to that, staff were frequently told to do the best they could with the available personnel. Residents reported feeling discouraged from requesting assistance due to staff communicating the ongoing staffing shortages. Staff members expressed concerns that inadequate staffing led to residents not being toileted or changed in a timely manner, increasing the risk for issues such as skin breakdown. The facility's own policy required sufficient and competent nursing staff to meet resident needs as determined by the facility assessment, but documented evidence showed that these standards were not consistently met.
Failure to Maintain Privacy and Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records for four residents. Specifically, LVN C did not close the electronic medical records (EMR) of three residents before entering their rooms to perform blood sugar checks and administer medications. This left the residents' medical information visible and accessible to others. LVN C acknowledged responsibility for closing the EMR and recognized the importance of maintaining confidentiality, stating that leaving the records open was a HIPAA violation. Additionally, a medication aide (MA G) failed to close a resident's EMR before entering the room to administer pain medication. The medication cart, with a laptop displaying the resident's information, was left unattended in a hallway where staff and residents were passing by. MA G admitted to forgetting to lock the screen due to being in a hurry and acknowledged it was her responsibility to ensure the screen was locked when unattended. Interviews with the Director of Nursing (DON) and the Administrator confirmed that leaving resident information visible on unattended screens was a violation of confidentiality policies and HIPAA regulations. Both stated that it was the responsibility of the staff using the medication cart to keep resident information confidential and not visible to unauthorized persons. Facility policies reviewed also emphasized the importance of safeguarding resident privacy and confidentiality.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, as identified through observations, interviews, and record reviews. For one resident with hemiplegia, diabetes, and anxiety disorder, the care plan did not address her use of a vape or smoking, despite documentation and staff acknowledgment that she engaged in these activities and required supervision when smoking. The MDS Coordinator confirmed awareness of the resident's smoking and vaping but stated these were not included in the care plan, which was acknowledged as an oversight. Another resident with schizoaffective disorder and mild intellectual disabilities, who was identified by the PASRR process as having serious mental illness and an intellectual disability, was receiving clozapine, an antipsychotic medication. The care plan for this resident did not specify the use of clozapine or include interventions related to its administration, nor did it address the resident's PASRR status. The DON confirmed that these aspects should have been included in the care plan and attributed the omission to a recent change in facility ownership. A third resident, diagnosed with vascular dementia, bipolar disorder, and mild cognitive impairment, resided in the memory care unit. The care plan for this resident addressed risks for wandering and elopement but did not mention the resident's placement in the memory care unit. The MDS Coordinator acknowledged that this information should have been included in the care plan and noted that recent organizational changes contributed to the oversight. Facility policy requires comprehensive, person-centered care plans to be developed and updated to reflect all identified needs and services, but this was not followed for these residents.
Failure to Specify Enteral Feeding Formula in Physician's Order
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition had a physician's order specifying the type of feeding formula to be administered. Record reviews showed that the resident, a female with cerebral palsy, epilepsy, hypertension, and a gastrostomy, had orders and care plans for tube feeding, but none of these documents indicated the specific type of enteral formula required. Observations confirmed that a specific formula (Jevity 1.5 cal) was present in the resident's room, but staff interviews revealed that, due to the lack of specificity in the order, any type of formula could potentially be administered. Nursing staff acknowledged that this omission could result in the resident receiving an incorrect formula. Further interviews with the DON and Administrator confirmed that orders for enteral nutrition should specify the exact product to be used, and that the absence of this information placed the resident at risk of receiving the wrong feeding. The facility's own policy required that enteral nutrition orders be complete, including the product name, but this was not followed in the resident's case. The deficiency was identified through observation, record review, and staff interviews.
Failure to Ensure Staff Competency in Medication Administration
Penalty
Summary
The facility failed to ensure that licensed staff, including nurses and medication aides, demonstrated the necessary competencies and skill sets required to safely administer medications according to physician orders. Specifically, three staff members were found to have administered antihypertensive medications to residents even when their blood pressure readings were outside the parameters specified in the physician's orders. Documentation on the Medication Administration Records (MARs) confirmed that medications were given despite blood pressure readings below the required thresholds, and staff interviews corroborated that these medications were administered inappropriately. Multiple residents with complex medical histories, including diagnoses such as cerebral palsy, epilepsy, hypertension, chronic obstructive pulmonary disease, and end-stage heart failure, were affected by these actions. For example, one resident with severe cognitive impairment and hypertension received metoprolol on several occasions when her blood pressure was below the ordered parameters. Similar incidents occurred with other residents who had orders for blood pressure medications to be held if their readings were too low, yet the medications were still administered by staff. Interviews with staff and administration revealed a lack of current competency checks for nurses and medication aides. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that competency checks had not been completed under the current company, and there was no accountability system in place to monitor proper medication administration. Review of facility policies and the facility assessment indicated that staff competency should be regularly evaluated and documented, but these requirements were not met, as evidenced by missing or outdated competency records.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically regarding the administration of metoprolol, a blood pressure medication, outside of physician-ordered parameters. For three residents reviewed, staff administered metoprolol even when blood pressure readings were below the minimum thresholds specified in the orders. For example, one resident with a history of hypertension, cerebral palsy, and epilepsy received metoprolol on three occasions when her systolic or diastolic blood pressure was below the ordered parameters. The medication administration records (MAR) confirmed that the medication was given despite these readings, and the nurse involved acknowledged the error during an interview. Another resident with chronic obstructive pulmonary disease, heart failure, and hypertension was also administered metoprolol on two occasions when her blood pressure was not within the required parameters. The MAR indicated that medication aides documented the administration of the medication despite blood pressure readings below the physician's specified limits. Similarly, a third resident with end-stage heart failure and hypertension received metoprolol on three occasions when his blood pressure was below the ordered parameters, as documented in the MAR and confirmed by staff interviews. Interviews with nursing staff and facility leadership revealed a lack of consistent monitoring and accountability regarding medication administration. Staff members were not always aware of the specific parameters for holding blood pressure medications, and facility leadership acknowledged challenges in reviewing MARs due to staffing constraints. Medication pass audits indicated previous issues with adherence to physician orders, and the facility's policy required orders to be consistent with safe and effective practices, which was not followed in these instances.
Failure to Properly Label and Secure Medications and Controlled Substances
Penalty
Summary
Surveyors identified multiple deficiencies related to the labeling and storage of drugs and biologicals. In one instance, a resident with intact cognitive function was found with bottles of Rexall, Purzee, and Melatonin on his bedside table, which had been brought in by a family member. These medications were not listed in the resident's order summary report, and staff interviews confirmed that the medications should not have been at the bedside, as this could result in the resident or others taking them inappropriately. The medications were subsequently removed by staff after the issue was identified. In another case, a lock box containing two bottles of Lorazepam, a controlled substance, was found in the medication room refrigerator but was not permanently affixed as required. The DON and Administrator both acknowledged that the lock box should have been secured to prevent removal, and that it was their responsibility to ensure compliance with this requirement. The lack of proper affixation was recognized as a failure to secure controlled substances according to facility policy and professional standards. Additional deficiencies were observed with another resident who had a prescription cream left unsecured on his nightstand over multiple observations, despite having severe cognitive impairment and a care plan indicating risk for impaired skin integrity. Furthermore, medication aides were observed leaving a medication cart unlocked and unattended, with keys attached to the narcotic drawer, while administering medications to residents. Staff interviews confirmed that medication carts should be locked and keys kept in possession when not in use, and that these lapses were contrary to facility policy and expectations.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide food that was consistently palatable, attractive, and served at a safe and appetizing temperature for at least one of three meals reviewed. Multiple residents reported dissatisfaction with the taste and temperature of the food, with specific complaints about food being cold and bland. During a group meeting, residents also noted that the food often contained too many herbs and was served cold. Direct observation and tasting by surveyors and the Dietary Manager confirmed that some meal components, such as the Spanish rice, were bland and not hot, and the churros lacked expected flavor. The Dietary Manager reported tasting foods in the kitchen only once a week and relied on staff to follow recipes by referencing the recipe book, with the last in-service on recipe adherence conducted over a month prior. The Administrator acknowledged receiving frequent food complaints and stated that test trays were ordered only a few times a month due to time constraints. There was no policy on following recipes provided during the survey, and the facility's approach to food complaints was to offer alternative meals. These actions and inactions contributed to the deficiency in providing meals that met palatability, attractiveness, and temperature standards.
Deficiencies in Food Labeling, Storage, and Hand Hygiene Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During observations in the kitchen and storage areas, multiple food items were found without proper labeling, preparation dates, or expiration dates. Some items, such as containers of cranberry juice, orange juice, Kool-Aid, unsweet tea, salami lunch meat, rotini pasta, and cilantro, were either missing required information or were not discarded after expiration. The Dietary Manager confirmed that all food items should be labeled and dated with receive, open, and expiration dates, and that staff had been in-serviced on these requirements. Additionally, a CNA was observed not sanitizing her hands between passing meal trays on one of the facility's halls. The CNA admitted to forgetting to sanitize her hands and stated she was aware of the requirement to do so between passing trays. The charge nurse and DON were not initially aware of the incident but confirmed that staff are expected to sanitize hands between meal tray distribution. The DON and Administrator both stated that hand hygiene is important for infection control and that in-services on hand hygiene are conducted, though neither could recall the exact timing of the last in-service for all staff. Record reviews of facility policies confirmed that all food items must be labeled, dated, and stored according to state and federal guidelines, and that hand hygiene procedures must be followed to prevent the spread of infections. The failure to follow these procedures was observed directly by surveyors and confirmed through staff interviews and record reviews.
Failure to Provide Required HIV and Restraint Training to Staff
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, specifically regarding HIV and restraint training. Record review revealed that five employees, including the Administrator, DON, ADON, and two LVNs, did not complete required HIV and restraint training upon hire. The employee files did not indicate that these trainings were completed, and there was also a lack of documentation for hire dates. Interviews with facility and corporate staff confirmed that not all employees had received the necessary trainings, attributing the lapse to a change of ownership and a failure to assign and monitor required trainings. Further interviews indicated that responsibility for ensuring completion of these trainings was shared between corporate HR, the facility HR manager, and supervisors. The corporate HR coordinator acknowledged that HIV and restraint training should be completed upon hire and annually, and that monitoring should occur during morning meetings. The Administrator also stated that corporate was responsible for providing information on required annual trainings, while the HR coordinator was responsible for ensuring completion. The facility's policy on required trainings was requested but not provided.
Failure to Maintain Resident Dignity by Not Covering Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure that a resident's right to dignity and privacy was maintained by not providing a privacy cover for the resident's Foley catheter drainage bag on two separate occasions. Observations showed that the catheter bag was left uncovered and visible to others, both from the resident's room and from the hallway, as the door was open. The resident, who had severe cognitive impairment and was unable to express whether the lack of privacy bothered her, had a physician's order and care plan intervention requiring the catheter bag to be covered at all times. However, the order was not reflected in the medication administration record, and staff interviews confirmed that the responsibility for ensuring the privacy cover was in place was shared among nurses and aides. Staff, including a CNA, LVN, DON, and the Administrator, acknowledged during interviews that not covering the catheter bag was a violation of the resident's privacy and dignity. The facility's dignity policy specifically prohibited practices that compromise dignity, including failing to keep urinary catheter bags covered. The facility's catheter care policy did not address privacy for catheter drainage bags. The resident involved had multiple diagnoses, including diabetes, dementia, malnutrition, and urinary retention, and was dependent on staff to uphold her rights and dignity due to her cognitive impairment.
Call Light Not Within Reach for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach while the resident was in bed, as observed on 04/21/2025. The resident, a female with hemiplegia and hemiparesis affecting her left side, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder, was found to have her call light hung over the foot of the bed, out of her reach. The resident requested assistance from the state surveyor to retrieve the call light so she could call for help with repositioning. The resident stated she did not know who placed the call light there and that it had been out of reach for too long. Her comprehensive MDS assessment indicated she was cognitively intact and dependent on staff for several activities of daily living, with functional limitations on one side of her body. Interviews with staff, including an LVN, CNA, DON, and the Administrator, revealed that staff were unsure why the call light was not within reach and acknowledged the importance of ensuring call lights are accessible to residents. The facility's policy required that each resident be provided with a means to call staff directly for assistance from their bed. The failure to ensure the call light was within reach was not in accordance with this policy and could prevent the resident from being able to request assistance when needed.
Failure to Honor Resident's Shower Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination by not providing showers as requested, instead giving bed baths on multiple occasions. The resident, a female with diagnoses including diabetes, stroke, and irritable bowel syndrome, was cognitively intact and able to communicate her preferences. Her care plan indicated a need for assistance with activities of daily living, including bathing, and specified maintaining a consistent daily routine. Documentation showed that on at least two occasions, bed baths were given instead of showers, and there was a lack of documentation for showers over a ten-day period. Interviews with the resident and staff confirmed that the resident had missed three showers in the past two weeks and that her preference for showers was known to staff. Staff reported that when the designated shower aide was reassigned, the responsibility for showers fell to the hall aide, who sometimes could not provide showers due to staffing constraints. Both the DON and the Administrator acknowledged that the resident had the right to receive showers as preferred and that her requests should have been met. The facility's policy also emphasized the right to self-determination and respect for resident preferences.
Failure to Update Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically an Out-of-Hospital Do Not Resuscitate (OOHDNR) order, was properly updated in the medical record after it was signed by the physician. The resident, a female with severe cognitive impairment and multiple diagnoses including cerebral palsy, epilepsy, hypertension, and gastrostomy status, had a face sheet indicating a full code status, despite her guardian having requested and signed a DNR that was later signed by the attending physician. The care plan noted the need to complete and update the advance directives document, but the order summary continued to reflect a full code status. Interviews with facility staff revealed a lack of clarity and follow-through regarding responsibility for updating the resident's code status. The Social Services Designee stated that after receiving a signed OOHDNR, she provided a copy to the nurses and uploaded it to the electronic medical record (EMR), but expected the nurses to update the code status. The ADON and LVN both indicated that in an emergency, they would rely on the code status displayed in the EMR or on the resident's door, and not review uploaded documents. The DON and Administrator both confirmed that the code status should have been updated immediately upon receipt of the signed OOHDNR, and acknowledged that failure to do so could result in actions contrary to the resident's wishes. Facility policy required that advance directives be honored and that copies be maintained in a readily retrievable section of the resident's medical record. The policy also specified that the DNS or designee notify the attending physician of any changes so that appropriate orders could be documented. Despite these requirements, the resident's code status remained listed as full code after the OOHDNR was signed and uploaded, resulting in a failure to honor the resident's advance directive as documented.
Failure to Repair Broken Light Cover in Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident by not repairing a broken light cover in the resident's room. The broken light cover was observed to be jagged, and both the resident and multiple staff members, including the Maintenance Director, LVN, DON, and Administrator, were aware of the issue. The Maintenance Director acknowledged having a replacement part but had not yet completed the repair, and the work order for the repair had been open for several weeks. The resident, who had intact cognition and was dependent on staff for several activities of daily living, reported that staff could see the broken cover but could not recall when it broke. The resident's medical history included hemiplegia and hemiparesis following cerebrovascular disease, type 2 diabetes mellitus with diabetic neuropathy, and anxiety disorder. Staff interviews confirmed awareness of the broken light cover and its potential to cause injury, as the resident could reach and touch the jagged edge. The facility's policy on resident rights referenced a dignified existence but did not specifically address maintaining a homelike environment. The deficiency was identified through observation, interviews, and review of facility records and policies.
Failure to Promptly Address and Document Resident Grievances Regarding Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents who reported missing clothing items. One resident, an elderly female with chronic obstructive pulmonary disease, diabetes, and heart failure, reported missing a pair of black pants and a green sleeveless V-neck shirt. She stated that the items had been missing for several months and that she had informed a staff member, though she could not recall who. Despite her reports, the missing items were neither found nor replaced, and no grievance was filed regarding her complaint. Another resident, also an elderly female with congestive heart failure, atrial fibrillation, and muscle weakness, reported missing a pair of black pants for several months. She consistently brought up the issue during resident council and town hall meetings, and it was documented in meeting notes. Despite her repeated complaints, the missing pants were not replaced until much later, and no formal grievance was filed. Interviews with staff confirmed that the missing clothing was reported to laundry and supervisors, but there was no documentation of a grievance or timely resolution. Record reviews and staff interviews revealed that the facility's grievance policy was not followed, as grievances regarding missing clothing were not documented or investigated as required. The social services designee and other staff acknowledged that complaints about missing clothing were brought to their attention, but grievances were not always filed unless the resident expressed significant distress. The facility's policy required prompt investigation and written response to grievances, which was not observed in these cases.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for two residents who required help with these tasks. Both residents had care plans indicating the need for assistance with bathing and maintaining a consistent daily routine, yet records and interviews revealed missed scheduled showers. Documentation showed gaps in shower records for both residents, with several dates lacking evidence that showers were provided as scheduled. One resident, an older female with diagnoses including congestive heart failure, atrial fibrillation, and muscle weakness, required supervision or touching assistance for personal hygiene and showering. She reported not receiving a shower since her last scheduled day and expressed feeling dirty as a result. Another resident, also an older female with diabetes, stroke, and irritable bowel syndrome, required substantial to maximal assistance with showering and upper body dressing. She reported missing three showers in the past two weeks and stated that she received bed baths instead when the shower aide was reassigned. Interviews with staff revealed that when the designated shower aide was reassigned to floor duties, the responsibility for providing showers shifted to the aides on each hall. However, this transition was not consistently managed, leading to missed showers and incomplete documentation. The DON and Administrator confirmed that showers were expected to be provided according to schedule and that the charge nurse was responsible for ensuring this occurred. The facility's policy emphasized the importance of bathing for cleanliness, comfort, and skin observation, but the lack of adherence to scheduled showers resulted in the deficiency.
Failure to Apply and Document Splint Use for Resident with Contracture
Penalty
Summary
A deficiency occurred when a resident with a right-hand contracture did not receive appropriate treatment and services to maintain or improve range of motion as ordered. The resident, who had a history of cerebral infarction, right upper arm muscle wasting, and right-hand contracture, was care planned to use a right palm guard splint to minimize contracture. Physician orders required the splint to be applied daily and removed at bedtime, with cleaning of the hand. However, multiple observations over several days showed the resident without the splint in place, and there were no interventions observed for the right hand. Record reviews revealed no documentation of the resident refusing the splint, despite staff interviews indicating that the resident sometimes refused the splint due to tenderness. The care plan did not indicate any refusals, and the treatment administration record showed the splint was being documented as applied, even when it was not. Nursing staff acknowledged that refusals should be documented in the progress notes and care plan, and that the splint should not be signed off as applied unless it was actually in place. The nurse responsible admitted to marking the medication administration record as completed before verifying the splint was applied. Interviews with the DON and Administrator confirmed that the nurse was responsible for ensuring the splint was applied as ordered, documenting refusals, and notifying leadership if there were issues. The facility's policy required residents with limited range of motion to receive treatment and services to prevent further decline, and for care plans to include specific interventions. The lack of proper application and documentation of the splint represented a failure to follow these requirements for the resident with a right-hand contracture.
Failure to Assess and Supervise Resident Vape Use
Penalty
Summary
A deficiency was identified when a resident was observed keeping a vape (electronic cigarette) on her over bed table, with no documentation that she had been evaluated for safe use of the device. The resident, who had diagnoses including hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and anxiety disorder, was cognitively intact but dependent on staff for several activities of daily living. Her care plan did not mention vape or smoking use, despite her being a tobacco user. Multiple staff interviews revealed inconsistent knowledge and practices regarding the storage and use of vape devices. Some staff were unsure if residents could keep vapes in their rooms, and there was confusion about whether smoking assessments applied to vape use. The Director of Nursing and Assistant Director of Nursing both indicated a lack of awareness about the resident's possession of the vape and the associated risks, while the Administrator stated that vapes should not be kept at the bedside and acknowledged responsibility for ensuring compliance. A review of facility policy indicated that residents using e-cigarettes should be assessed for their ability to safely handle the devices, receive instruction on battery safety, and have this documented in their care plan. However, there was no evidence that these steps had been taken for the resident in question. The facility's incident records did not show any vape-related incidents during the review period.
Failure to Secure Indwelling Catheter as Ordered
Penalty
Summary
A deficiency was identified when a resident with an indwelling foley catheter was observed to have the catheter unsecured to her leg, contrary to physician orders and the facility's care plan. The resident, an elderly female with diagnoses including diabetes, dementia, protein calorie malnutrition, and urine retention, had a care plan and physician order requiring the catheter to be secured with a stabilizer and checked every shift. Despite documentation indicating compliance, direct observation revealed the catheter was not secured, and both a CNA and an LVN confirmed the absence of a securement device during their checks. The LVN noted that the resident often removed the adhesive part of the securement device, but acknowledged the catheter should be properly secured to prevent trauma or bleeding. Interviews with facility staff, including the DON and Administrator, confirmed the expectation that catheters be properly secured and that it was the responsibility of the nursing team to ensure this. The facility's policy on urinary catheter care also required the use of a securement device to prevent complications. The failure to secure the catheter as required was directly observed and acknowledged by staff, representing a lapse in following established care protocols for catheter management.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required such care, as observed and documented by surveyors. For one resident, who had diagnoses including dementia, hyperlipidemia, bradycardia, and hypertension, the physician's order specified oxygen administration at 2-3 liters per minute via nasal cannula as needed for shortness of breath. However, during observation, the resident was found receiving oxygen at 4.5 liters per minute, exceeding the prescribed range. Interviews with the DON and Administrator revealed a lack of documentation regarding any resident manipulation of the oxygen concentrator and uncertainty about when staff were last in-serviced on oxygen concentrator use. Both the DON and Administrator stated that monitoring the oxygen settings was the responsibility of the charge nurses, but neither could confirm consistent oversight or recent staff training on this process. For another resident with chronic obstructive pulmonary disease, heart failure, and hypertension, the care plan and physician's orders required oxygen therapy as needed, with specific instructions to maintain oxygen saturation above 92%. During multiple observations, the resident's nasal cannula was found improperly stored—hanging from the bed rail or placed on top of the oxygen concentrator, and not kept in a bag as required for infection control. The resident confirmed that the nasal cannula was never stored in a bag, and staff interviews corroborated that the cannula should be bagged to prevent contamination. The ADON and DON both stated that all staff were responsible for ensuring proper storage, but acknowledged that this was not consistently done. The facility's policy on oxygen administration outlined procedures for safe oxygen delivery but did not address the storage of nasal cannulas. Despite this, staff interviews indicated an expectation for nasal cannulas to be stored in bags to prevent infection. The lack of adherence to physician orders for oxygen flow rates and improper storage of respiratory equipment constituted failures to follow professional standards of practice for respiratory care.
Failure to Complete Trauma Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma received trauma-informed and culturally competent care in accordance with professional standards of practice. Specifically, the resident, who had diagnoses including post-traumatic stress disorder (PTSD), anxiety disorder, and Wernicke's encephalopathy, did not have a trauma screening or assessment completed upon admission. The resident's comprehensive care plan did not address PTSD, and there was no documentation identifying possible triggers related to the resident's trauma history. Interviews with facility staff, including the Social Worker, DON, and Administrator, confirmed that the trauma assessment was not completed as required by facility policy. The Social Worker acknowledged responsibility for trauma assessments and recognized the importance of such assessments for staff awareness and care planning. The DON and Administrator also confirmed their expectations that trauma assessments be completed on admission and identified the lack of assessment as a failure to provide appropriate care for trauma survivors.
Failure to Accurately Document Controlled Substance Administration
Penalty
Summary
The facility failed to establish and maintain an adequate system for the receipt and disposition of controlled drugs, specifically for one resident who was prescribed acetaminophen-codeine for pain management. On the observed date, a medication aide (MA) prepared and administered the resident's scheduled dose of acetaminophen-codeine but did not document the administration on the resident's narcotic record as required. The MA acknowledged forgetting to sign the narcotic record due to being nervous while observed by a surveyor and recognized that this omission could result in a miscount of controlled medications. The resident involved was an older adult with chronic obstructive pulmonary disease, diabetes, and heart failure, who was cognitively intact and received regular opioid medication for pain. Interviews with the Director of Nursing (DON) and the Administrator confirmed that facility policy requires immediate documentation of controlled substance administration on the narcotic record by the person administering the medication. Both stated that failure to document could cause discrepancies in the controlled drug count. Review of facility policies further indicated that controlled substances must be reconciled upon administration and that the administering nurse is responsible for recording all required details immediately after giving the medication.
Failure to Complete Required Smoking Assessments for Resident Using Vape Device
Penalty
Summary
The facility failed to follow its established smoking policy for one resident who was reviewed for smoking practices. The resident, a female with hemiplegia, hemiparesis, type 2 diabetes with neuropathy, and anxiety disorder, was observed with a vape device on multiple occasions. Her comprehensive assessment indicated intact cognition and dependence on staff for several activities of daily living, and it was documented that she used tobacco. However, her care plan did not mention vaping or smoking, and there was no record of a completed safe smoking evaluation in her electronic health record. Interviews with staff revealed confusion and inconsistency regarding responsibility for completing smoking assessments. Some staff believed the MDS nurse was responsible, while others thought social services or charge nurses handled the assessments. The DON and ADON acknowledged that quarterly smoking assessments were required by policy, but could not confirm that these had been completed for the resident in question. The ADON also stated that the smoking assessment did not apply to vaping, despite the resident's use of a vape device. The facility's smoking policy required evaluation of smoking status and safe smoking ability upon admission, quarterly, and upon significant change in condition. Despite this, the resident's records lacked documentation of a safe smoking evaluation, and staff interviews confirmed that the required assessments had not been completed as per policy. This failure to follow the established policy was observed and confirmed through record review and staff interviews.
Failure to Protect Residents from Abuse Due to Inadequate Response to Escalating Behaviors
Penalty
Summary
The facility failed to protect residents from abuse, specifically involving two residents who were subjected to physical aggression by another resident. The incidents occurred over a period of several days, during which the aggressive resident exhibited escalating behaviors that were not adequately addressed by the facility staff. Despite being aware of the resident's potential for aggression due to dementia, the facility did not implement effective measures to prevent harm to other residents. The aggressive resident, who was severely cognitively impaired, displayed a series of behaviors including wandering, entering other residents' rooms, and physical aggression towards staff and residents. On one occasion, the resident kicked another resident's feet, and on another, the resident attempted to choke a fellow resident. These behaviors were documented in progress notes, but the facility staff failed to recognize the escalation and did not take appropriate action to mitigate the risk. Interviews with staff revealed a lack of communication and inadequate response to the escalating behaviors. The staff did not notify the physician or implement one-to-one monitoring, which could have prevented the incidents. The Director of Nursing and Assistant Director of Nursing were informed of the behaviors but did not consider them to be escalated, and the facility did not have sufficient staff to provide the necessary supervision. This inaction led to an Immediate Jeopardy situation, as the facility did not ensure the safety and protection of its residents from abuse.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents and resident-to-resident altercations. This deficiency was particularly evident in the case of a male resident with severe cognitive impairment and a history of aggressive behaviors. Despite displaying increased agitation and aggressive behaviors towards other residents, the facility did not increase supervision or implement effective interventions to manage his behavior. This lack of action led to a serious incident where the resident physically attacked another resident, attempting to choke her, which was only stopped by the intervention of a CNA. The resident in question had a history of dementia and was on multiple medications for behavior management, including Diazepam, Seroquel, Trazodone, and Wellbutrin. Despite these measures, the resident exhibited wandering, physical, and verbal aggression, and was not adequately assessed for his needs in various daily activities. The facility's records indicated multiple instances of the resident's escalating behaviors, such as entering other residents' rooms, removing his pants in common areas, and physically interacting with other residents, yet these behaviors were not effectively managed or reported to the physician for further intervention. Interviews with staff revealed a lack of adequate staffing and supervision, which contributed to the incident. Staff members reported the resident's behaviors to the Director of Nursing (DON) and Assistant Director of Nursing (ADON), but no effective measures were taken to address the escalating situation. The facility's failure to provide 1:1 supervision or to notify the physician of the resident's change in condition resulted in a serious safety breach, culminating in the resident's attack on another resident. This incident highlighted the facility's inability to manage residents with challenging behaviors, placing other residents at risk of harm.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required timeframe. On January 12, 2025, a resident kicked another resident's feet while he was sitting in his wheelchair. This incident was not reported to the facility administrator or the Health and Human Services Commission (HHSC) as required by the facility's policy and state law. The incident was also not documented in the facility's Incident and Accidents Report. The resident who committed the act had a history of severe cognitive impairment and exhibited wandering behavior, as well as physical and verbal behaviors towards others. Despite these behaviors, the facility did not take appropriate action to report the incident or investigate it as a potential case of resident-to-resident abuse. The staff involved, including an LVN, failed to complete an incident report or notify the appropriate authorities, citing a change of shift as a reason for the oversight. Interviews with facility staff, including the DON and ADON, revealed a lack of consensus on whether the resident's behaviors were considered escalated. The DON initially downplayed the incident, suggesting it could have been accidental, but later acknowledged it should have been reported and investigated. The facility's policy clearly states that all altercations should be reported and investigated, yet this protocol was not followed, placing residents at risk of abuse and harm.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
