Corinth Rehabilitation Suites On The Parkway
Inspection history, citations, penalties and survey trends for this long-term care facility in Corinth, Texas.
- Location
- 3511 Corinth Parkway, Corinth, Texas 76208
- CMS Provider Number
- 676319
- Inspections on file
- 50
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Corinth Rehabilitation Suites On The Parkway during CMS and state inspections, most recent first.
The facility failed to ensure accurate documentation of controlled substance counts on one medication cart when an LVN did not sign the controlled drug count sheet at shift changes on multiple occasions, despite facility policy requiring counts and signatures at each change of shift. Record review showed missing off-duty and on-duty signatures on several dates for the Hall 100 cart, and the DON confirmed that staff are trained and expected to sign after completing counts together. The LVN reported that she performed the counts but found the count sheet format confusing and did not sign as required, resulting in incomplete documentation of controlled drug accountability.
A resident with multiple chronic conditions and intact cognition had a physician’s order for one 5% Lidocaine patch to be applied to the left hip each morning and removed in the evening. On one morning, a medication aide applied the ordered patch, and shortly afterward an LVN, who was also passing medications, applied a second Lidocaine patch to the same general area after not seeing the first patch, which was positioned higher on the hip and partially covered by briefs. The resident later reported to the DON that staff had applied an additional patch, and the DON and administrator confirmed the presence of two patches, demonstrating a failure to follow the physician’s order and the facility’s medication management policy requiring adherence to the “8 Rights” of medication administration and that the same authorized person prepare, administer, and record medications.
A resident with dementia and hypertension, who required assistance with ADLs and had intact cognition, was observed with long chin hair despite a care plan goal to remain well-groomed and a facility policy to provide necessary grooming care. The resident reported receiving regular showers and repeatedly asking staff to shave her chin hair, but was told there were no razors. Staff interviews revealed that CNAs were responsible for grooming, including facial hair removal for female residents, that disposable razors were available, and that charge nurses were expected to ensure appropriate daily care. The DON confirmed razors were part of grooming supplies and that she had not been informed of the resident’s request, indicating the resident’s grooming needs and expressed preferences for facial hair removal were not met.
A CNA failed to follow infection control practices during incontinence care for a resident with multiple medical conditions, including a femoral neck fracture and generalized muscle weakness. After cleaning the resident’s perineal and buttocks areas, which included a bowel movement, the CNA did not change gloves or perform hand hygiene before applying a clean brief and repositioning the resident. The CNA later acknowledged knowing he should change gloves and perform hand hygiene when moving from dirty to clean tasks but did not do so. The DON confirmed that facility policy and expectations required hand hygiene before and after care and between dirty and clean activities, and the written hand hygiene policy required hand hygiene after contact with soiled items and after glove removal.
Staff failed to follow Enhanced Barrier Precautions and hand hygiene protocols for two residents with infectious disease histories. An LPN and a CNA did not wear gowns during high-contact care for a resident on EBP, and another CNA did not wear a gown or perform hand hygiene between glove changes while providing incontinent care to a different resident. These actions were inconsistent with the residents' care plans, posted signage, and facility policy.
A resident with a history of falls and requiring maximum assistance attempted to transfer independently after staff did not respond to his call light, resulting in a fall and a call to 911 for help. Both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assigned staff assistance. The DON did not initially interview the resident or contact EMS, and the incident was not self-reported as neglect as required by facility policy.
A resident with a history of falls and requiring maximum assistance for transfers fell while attempting to use the bathroom after staff failed to respond to his call light. Both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assistance. The resident called 911 for help, and EMS assisted him. The facility did not thoroughly investigate the incident, as the DON did not initially interview the resident or contact EMS, and was unaware that both assigned staff were absent during the fall.
A resident with a history of falls and requiring maximum assistance for transfers fell while attempting to use the bathroom after staff failed to respond to his call light. Both the CNA and RN assigned to the resident were on break at the same time, leaving the resident unsupervised. The resident called 911 for help after the fall, and the DON did not initially interview the resident as part of the investigation.
Several dependent residents did not receive necessary assistance with personal hygiene, including nail care and scheduled showers. Observations found long, dirty fingernails and missed showers, with staff interviews revealing confusion about responsibilities and inconsistent documentation. These failures occurred despite facility policies requiring regular ADL care and monitoring.
A CNA failed to provide timely and appropriate perineal care to a female resident with severe cognitive impairment and incontinence, omitting critical cleaning steps and not performing care as frequently as required by facility policy. The resident was found with wet, reddened skin and soiled bedding, and the CNA admitted to missing care due to being busy. The DON confirmed that proper perineal care, including cleaning the labia, is essential and expected.
The facility did not ensure that RNs responsible for two medication carts consistently counted and signed for controlled substances at each shift change, as required by policy. Record reviews showed missing signatures on narcotic count sheets, and interviews revealed that counts were performed but signatures were omitted due to being busy or misunderstanding procedures. The DON confirmed that both incoming and outgoing nurses are expected to sign immediately after counting.
Surveyors found that food items in the kitchen, including frozen French fries and biscuit dough, were not properly dated, labeled, or covered, and hamburger buns in dry storage lacked required labeling. Staff interviews confirmed that all kitchen staff were responsible for ensuring food items were stored according to policy, but these standards were not met.
Staff failed to disinfect a blood pressure cuff between use on two residents and did not follow proper hand hygiene or PPE protocols during care of a resident on Enhanced Barrier Precautions, including not wearing gowns and not sanitizing hands when changing gloves, despite facility policies and training.
Two residents were permanently discharged without completed discharge summaries in their electronic medical records, despite facility policy requiring interdisciplinary documentation for all permanent discharges. One resident, a respite admission under hospice care, and another with severe cognitive impairment and multiple diagnoses, both lacked the necessary discharge summaries, as confirmed by staff interviews and record review.
A resident with a history of falls and multiple medical conditions experienced a fall in the bathroom. Although the resident was assessed and family notified, the charge nurse did not promptly notify the physician as required by facility policy, only doing so the following day after being instructed. Interviews confirmed the nurse was unaware of the fall notification protocol, resulting in a failure to follow professional standards of practice.
A resident on continuous oxygen therapy did not have their oxygen humidification bottle and nasal cannula tubing changed according to the required weekly schedule, as observed by surveyors. The equipment was found to be overdue for replacement, and staff interviews confirmed that the change had not occurred as per physician orders and facility policy, resulting in a lapse in infection control practices.
A resident with severe cognitive deficit did not receive privacy during insulin administration by an LVN, as captured by a Ring camera. The resident was uncovered and in a vulnerable state, and the privacy curtain was not drawn. The facility's policy on maintaining resident dignity and privacy was not followed, as confirmed by the DON and Administrator.
A resident with moderate cognitive impairment experienced a witnessed fall while under one-to-one observation, leading to an allegation of neglect. Although the incident was reported to Texas Health and Human Services the following day, the facility failed to submit the required investigation report within the five-day timeframe. The previous administrator, responsible for the report, was suspended and later terminated, resulting in a delay that risked timely state review.
A resident with a history of falls was not properly assessed after a witnessed fall in a facility. An LVN failed to conduct an immediate post-fall assessment, including checking vital signs and range of motion, before assisting the resident to the bathroom. The incident was captured on a Ring camera, revealing the LVN's failure to follow the facility's fall management protocol.
An LVN failed to perform hand hygiene and change gloves between administering medications to two residents, as captured by video footage. The residents, both with cognitive impairments and multiple health conditions, were at risk due to this breach in infection control protocols. The DON confirmed the LVN's failure to adhere to the facility's infection control policies.
The facility failed to ensure that residents, family members, and legal representatives had easy access to view the nursing home's survey results. Residents were unaware of the location of the survey results and their right to review them. The Activities Director and Administrator were unclear about the exact location and communication of these results, despite policies indicating that residents should be informed.
The facility failed to investigate allegations of neglect for two residents. One resident experienced an unwitnessed fall resulting in a pelvis fracture, and another had a family member report neglect due to soiled bed sheets. Despite self-reports being made, no investigations were conducted, and staff were not questioned about the incidents.
A facility failed to develop a comprehensive care plan for a resident who stored fresh produce in unsanitary conditions, leading to potential health risks. Despite staff awareness, the care plan did not address the issue, resulting in a lack of coordinated care.
The facility failed to maintain a resident's personal hygiene by not ensuring his fingernails were cleaned and trimmed. The resident, who required maximal assistance due to dementia and other conditions, was found with long, discolored nails. Staff interviews revealed a lapse in daily nail care observation and adherence to the facility's grooming policy.
A facility failed to provide proper perineal care for a resident with incontinence, leading to a risk of urinary tract infections. CNA A did not follow the correct procedure of cleaning from front to back and failed to change gloves or perform hand hygiene when moving from dirty to clean tasks. The resident had multiple diagnoses, including dementia and muscle wasting, and required maximal assistance with personal hygiene.
The facility failed to ensure that medications in unsecure containers were removed from the Med Aide Cart, posing risks of drug diversion and infection control issues. A controlled medication blister pack was found with a broken seal and taped over, and the responsible Med Aide was unaware of the damage.
The facility failed to maintain an infection control program, as a CNA did not perform hand hygiene or change gloves during incontinence care for a resident, and an LVN did not sanitize hands after conducting an FSBS test and cleaning the glucometer before administering insulin to another resident.
Failure to Document Controlled Drug Shift Counts on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper pharmaceutical services and controlled substance accountability on one of four medication carts reviewed, specifically the Medication Cart on Hall 100. Record review of the controlled medication count sheet for this cart showed missing signatures for both off-duty and on-duty nurses at shift changes on four separate dates (02/03/26, 02/06/26, 02/08/26, and 02/12/26). The facility’s policy, dated 01/15/25 and titled “Medication Management Program,” requires that controlled substances be counted by authorized staff at each change of shift and accounted for on a controlled substance record. The absence of required signatures indicated that the facility did not consistently document that these counts were completed as required. During interviews, the DON stated that staff were trained to perform controlled drug counts at the beginning and end of their shifts on their assigned medication carts and that nurses were expected to sign the medication count sheet after completing the count with the incoming or off-going nurse. The DON also stated that missing signatures meant she could not prove that the staff had successfully completed the counts. An LVN assigned to the Hall 100 cart acknowledged that she did not sign the medication count sheet on the identified dates, explaining that she found the layout of the sheet confusing because she had to sign on different sides and lines when signing on and off. She stated that she understood the importance of signing the sheet as proof that the count was done and reported that she did perform the counts as required, but failed to document them with her signature.
Double Application of Lidocaine Patch Contrary to Physician Order
Penalty
Summary
The deficiency involves the facility’s failure to administer medication according to a physician’s order when a resident received two Lidocaine (Lidoderm) patches instead of the prescribed single patch. The resident was an adult male with multiple diagnoses including HIV, seizures, neuromuscular dysfunction, paraplegia, hypertension, depression, anxiety, and other conditions, and had an intact cognition with a BIMS score of 15. A physician’s order dated 01/04/26 directed that one 5% Lidocaine patch be applied topically to the left hip at 9:00 AM and removed at 9:00 PM. On 01/16/2026, the Medication Administration Record showed that a medication aide administered the ordered Lidocaine patch to the resident at 9:00 AM, and the aide later stated that when she applied the patch, the resident did not already have one on. Shortly thereafter, an LVN, who was also passing medications, applied an additional Lidocaine patch to the resident’s left lower hip area. The LVN reported that she had given the resident his medications, left to obtain the Lidocaine patch, and upon returning did not see an existing patch, which she stated must have been applied in the interim. She further stated that the resident, who was verbal and able to direct where he wanted the patch placed, did not inform her that a patch had just been applied. The situation was discovered when the resident reported to the DON that staff had applied an additional Lidocaine patch. The DON and the administrator both confirmed that the resident had two Lidocaine patches on his left hip, with one patch located higher up and partially covered by the resident’s briefs. The LVN later found the first patch higher on the left hip than where she had placed the second patch and stated that the patch may have moved or been moved by the resident. The facility’s Medication Management Program policy required adherence to the “8 Rights” of medication administration and specified that the same authorized person should prepare, administer, and record medications, but in this instance, two different staff members applied Lidocaine patches, resulting in a double application contrary to the physician’s order.
Failure to Provide Grooming Assistance for Facial Hair Removal
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for one resident. The resident was an older female with non-Alzheimer’s dementia and hypertension whose Quarterly MDS showed a BIMS score of 13, indicating intact cognition, and a need for partial/moderate assistance with showering/bathing. Her care plan, revised 12/10/25, documented that she required assistance with ADLs related to visual impairment, weakness, and impaired cognition, with a goal to remain clean, dry, odor-free, and well-groomed, and an approach indicating extensive to total one-person assistance with bathing. On observation, the resident was seen sitting at the edge of her bed with scattered chin hair approximately 3/4 inch long. She reported receiving regular showers on a Monday-Wednesday-Friday schedule and stated she had been asking staff to shave her chin hair, but was told that, per facility policy, there were no razors in the facility. She reported feeling embarrassed, avoiding leaving her room, eating in her room, and not going to the dining room because of her facial hair. Interviews with staff confirmed that CNAs were responsible for showers and grooming, including facial hair removal for female residents, and that the facility did have disposable razors for resident use. LVN B stated that CNAs should inspect and trim or shave female residents’ facial hair weekly on shower days according to resident preference, and that charge nurses were responsible for ensuring residents received appropriate and consistent daily care. CNA A stated CNAs were responsible for shaving/removing facial hair on shower days and as needed, and acknowledged the facility had disposable razors, adding that he did not know who told the resident that the facility did not have razors. The DON stated CNAs were supposed to shave/remove female residents’ facial hair on shower days or as desired by the resident, confirmed that razors were part of residents’ grooming supplies, and stated she had not been notified that this resident had facial hair and wanted to be shaved. The facility’s “Activities of Daily Living, Optimal Function” policy stated the facility provides necessary care to residents unable to carry out ADLs to ensure they maintain proper grooming and hygiene. Despite this policy and the resident’s care plan, the resident’s request for facial hair removal was not carried out, resulting in unaddressed grooming needs on the date of observation.
Failure to Perform Hand Hygiene and Change Gloves During Incontinence Care
Penalty
Summary
The deficiency involves a failure to maintain proper infection prevention and control practices during incontinence care for one resident. The resident was an older female with diagnoses including hypertension, a left femoral neck fracture, muscle wasting and atrophy, and generalized muscle weakness. Her Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and she was frequently incontinent of bladder. During an observation of incontinence care, a CNA entered the resident’s room, performed hand hygiene, and donned gloves. He unfastened the resident’s brief and cleaned the front pubic area with peri wipes, then assisted her onto her left side, removed and discarded the soiled brief, and cleaned the buttocks area, during which a medium bowel movement was present. After completing cleaning of the soiled areas, the CNA did not change gloves before proceeding to place a clean brief under the resident, reposition her onto her back, fasten the clean brief, cover her, and lower the bed. He then gathered dirty clothes and trash, removed his gloves, performed hand hygiene, and exited the room. In an interview, the CNA acknowledged he was supposed to change gloves and perform hand hygiene each time he moved from a dirty to a clean area during care and stated he did not do so because he was nervous about being observed. The DON confirmed that staff were expected to perform hand hygiene before and after care and to change gloves and perform hand hygiene between dirty and clean tasks, as the hands are considered dirty after cleaning the resident. The facility’s hand hygiene policy required hand hygiene after contact with soiled or contaminated articles and after removal of gloves.
Failure to Adhere to Enhanced Barrier Precautions and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents on Enhanced Barrier Precautions (EBP). For one resident with a history of multidrug-resistant organism (MDRO), both an LPN and a CNA entered the resident's room to assist with a mechanical lift transfer and other care activities without donning required gowns, although they wore gloves and performed some hand hygiene. The resident's care plan and EBP signage indicated that gowns and gloves were required for close contact care, but staff did not comply. The LPN acknowledged that transferring and adjusting the resident, as well as changing oxygen equipment, constituted high-contact care requiring full PPE, and the CNA stated she only wore a gown during showers, not for other care activities. For another resident with a history of ESBL in urine, a CNA performed incontinent care without wearing a gown and failed to perform hand hygiene between glove changes. The CNA wore gloves but did not sanitize hands between glove changes, despite handling soiled briefs and cleaning the resident. The CNA later stated she misunderstood the EBP signage, believing it applied to the roommate, and noted that the hand sanitizer dispenser was outside the room. The resident's care plan and facility policy required proper PPE use and hand hygiene for all staff providing care to residents on EBP. Interviews with the ADON, who also served as the Infection Preventionist, and the DON confirmed that their expectations were for staff to wear appropriate PPE and perform hand hygiene during all close contact care for residents on EBP. Facility policies reviewed also required hand hygiene before and after resident contact and after glove removal, as well as adherence to PPE requirements based on transmission-based precautions.
Failure to Timely Report and Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to ensure timely reporting and investigation of an allegation of neglect involving a male resident with intact cognition, multiple diagnoses including unsteadiness on feet, and a high risk for falls. The resident, who required maximum assistance for transfers, fell in the bathroom after attempting to transfer independently when staff did not respond to his call light. He subsequently called 911 for assistance, and emergency medical services helped him back into his wheelchair. Documentation indicated that the resident's call light was within reach, but he did not use it to call for help before transferring; however, during interview, the resident stated he had pressed the call light and waited as long as he could before attempting to transfer on his own due to lack of staff response. Interviews and record reviews revealed that both the CNA and RN assigned to the resident were on break at the same time, leaving the resident without assigned staff assistance. Other staff members were present in the building, but not assigned to the resident's hall. The Director of Nursing (DON) investigated the fall by speaking to staff but did not interview the resident initially, nor did she contact EMS for additional information. The DON was unaware that both assigned staff were on break simultaneously and did not self-report the incident as neglect because she did not realize the full circumstances at the time. The facility's policy requires immediate reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, to the administrator and appropriate authorities. In this case, the incident was not self-reported as neglect, and the required investigation steps, including interviewing the resident and contacting EMS, were not completed in a timely manner. The administrator later acknowledged that if she had known both assigned staff were on break, she would have self-reported the incident as neglect.
Failure to Investigate Alleged Neglect After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a male resident with intact cognitive ability, who was at risk for falls due to immobility, muscle weakness, diabetes, and chronic pain. The resident required maximum assistance for transfers and had a care plan intervention to keep the call light within reach at all times. On the night of the incident, the resident attempted to transfer from his wheelchair to the toilet independently after waiting for staff assistance that did not arrive, resulting in a fall. He called 911 for help, and emergency personnel assisted him back into his wheelchair. Documentation indicated that the resident was alert, oriented, and had no injuries, but staff education was provided regarding the use of the call light system. Interviews and record reviews revealed that both the CNA and RN assigned to the resident were on break at the same time when the fall occurred, leaving the resident without immediate assistance. The resident reported pressing his call light and waiting as long as he could before attempting the transfer himself. He also stated that he yelled for help after falling, but no staff responded, prompting him to call 911. Other staff confirmed that the assigned CNA and RN were outside on break, and the DON was unaware that both were absent from the unit simultaneously. The facility's investigation into the incident was incomplete, as the DON did not initially interview the resident or contact EMS for additional information. The DON relied on staff accounts and did not recognize the need to self-report the incident as neglect, as she was unaware that both assigned staff were on break at the same time. The facility policy required prompt investigation of any allegations of abuse, neglect, or mistreatment, but this was not fully carried out in this case.
Failure to Provide Adequate Supervision and Timely Assistance Leads to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was at risk for falls. The resident, a male with intact cognitive ability, non-Alzheimer's disease, unsteadiness on his feet, and requiring maximum assistance for transfers, was found on the bathroom floor after attempting to transfer independently from his electric wheelchair to the toilet. The resident's care plan identified him as a fall risk due to immobility, muscle weakness, diabetes, and chronic pain, and included interventions such as keeping the call light within reach at all times. On the night of the incident, the resident reported pressing his call light to request assistance to use the bathroom but stated that staff did not respond in a timely manner. After waiting as long as he could, he attempted the transfer himself, resulting in a fall. The resident then called 911 for help, as no staff responded to his calls for assistance after the fall. Emergency medical services arrived and assisted him back into his wheelchair. At the time, both the CNA and nurse assigned to the resident's hall were on break simultaneously, leaving the resident without adequate supervision. Interviews with staff and the DON revealed that staff were not supposed to take breaks at the same time, but both the CNA and RN assigned to the resident were outside on break when the fall occurred. The DON did not initially interview the resident as part of the fall investigation and was unaware that the resident had called for help and received no response. The facility's fall management policy required identification of fall risks, planning and implementation of interventions, and thorough investigation of falls, including interviewing the resident and staff, but these steps were not fully followed in this case.
Failure to Provide Necessary ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene, for several residents who were dependent on staff for these tasks. Multiple residents with severe cognitive impairment, physical disabilities, or blindness were observed to have long, dirty, and untrimmed fingernails. In several cases, residents expressed that they could not trim their own nails and wanted staff assistance, but their needs were not met. Staff interviews revealed confusion about responsibilities for nail care, particularly for diabetic residents, and a lack of awareness regarding the condition of residents' nails. Additionally, the facility did not consistently provide scheduled showers or baths for a resident who was totally dependent on staff for bathing and personal hygiene. Documentation showed that this resident missed multiple scheduled showers, with no records of refusals or alternative care being provided. Staff interviews indicated that showers and refusals were supposed to be documented and reported to the charge nurse, but this process was not consistently followed. The resident confirmed that she had not received showers for an extended period and wanted to be showered. Record reviews and staff interviews further highlighted that the facility's policies required daily observation and as-needed care for personal hygiene, including nail care and bathing. However, there was a lack of adherence to these policies, as evidenced by the missed care and inconsistent documentation. The failures in providing necessary ADL care were observed directly by surveyors and confirmed through interviews with residents and staff.
Failure to Provide Timely and Appropriate Perineal Care for Incontinent Resident
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide timely and appropriate perineal care to a female resident who was always incontinent of urine and bowel. The resident, who had diagnoses including Down syndrome, dementia, and a severe cognitive communication deficit, required moderate assistance with toileting and personal hygiene. During an observation, the CNA did not separate the resident's labia while cleaning, missing a critical step in perineal care, and the resident was found to have soaked through her brief and bed sheet, with her skin noted to be wet and red but intact. The CNA admitted to missing this step and acknowledged its importance in preventing infection. Further review revealed that the CNA had not provided any incontinent care to the resident since the start of her shift, despite facility policy and the resident's care plan requiring incontinence care after each episode and at least every two hours. The CNA stated she was busy and had not yet checked on the resident. The Director of Nursing confirmed that proper perineal care, including cleaning the labia, is expected and that failure to do so places residents at risk. Facility policy and CDC guidelines emphasize the importance of good perineal hygiene to prevent urinary tract infections.
Failure to Document Controlled Substance Counts at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for two medication carts (Hall 200 and Hall 300) out of four reviewed. Specifically, the responsible RNs did not consistently count controlled drugs at every change of shift and did not sign the narcotic sheet form after the count, as required by facility policy. Record reviews revealed multiple dates with missing signatures for both off-duty and on-duty nurses on the narcotic count sheets for both medication carts. Interviews with the involved RNs confirmed that the counts were performed but the required signatures were omitted, either due to being busy or misunderstanding the policy. One RN was new and had only recently received in-service training on the correct procedure. The DON confirmed that the expectation is for both incoming and outgoing nurses to sign the narcotic count sheet immediately after counting, and acknowledged that missing signatures prevent verification that counts were completed as required. The facility's policy mandates that both staff members sign the controlled substance shift change sheet to verify the accuracy of the medication counts at each shift change.
Failure to Properly Store, Label, and Cover Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's only kitchen regarding the storage, preparation, and handling of food items. Specifically, frozen French fries in the walk-in freezer were not dated, and frozen southern style biscuit dough was left uncovered in a plastic bag inside an open cardboard box. In the dry storage area, three hamburger buns wrapped in a plastic bag were found without any date or label. These observations were confirmed through interviews with the Dietary Manager, a cook, and a dietary aide, all of whom acknowledged that food items should be dated, labeled, and covered according to facility policy and professional standards. The facility's policy on food safety and the FDA Food Code require that all food items removed from their original packaging be labeled with the common name, open date, and discard date, and be stored in leak-proof, pest-proof containers with tight-fitting lids. Staff interviews revealed that responsibility for proper food storage was shared among all kitchen staff, including the Dietary Manager, cooks, and dietary aides. The staff recognized that failure to properly store food could result in food spoilage and increased risk of illness, and acknowledged that the observed deficiencies did not meet the facility's stated expectations or regulatory requirements.
Infection Control Lapses in Equipment Disinfection and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices observed among staff caring for three residents. During a morning medication pass, a medication aide did not disinfect a reusable blood pressure cuff before or after use between two residents, despite being aware of the requirement to do so. The aide admitted to forgetting this step due to nervousness and being new to the role. The Director of Nursing confirmed that staff had been trained on this expectation and that competency checks were in place. In another instance, two certified nursing assistants (CNAs) did not perform proper hand hygiene when changing gloves during morning care for a resident who was on Enhanced Barrier Precautions (EBP) due to an indwelling Foley catheter. The CNAs were observed changing gloves multiple times without sanitizing their hands, and one CNA did not wear a gown as required for EBP. Both CNAs handled the resident’s personal care, including peri-care and device care, without adhering to the facility’s infection control protocols for hand hygiene and personal protective equipment (PPE). Interviews with the involved staff revealed gaps in knowledge and adherence to infection control procedures, with one CNA stating she forgot to wear a gown and did not carry hand sanitizer, while the other was unaware of the need for a gown for residents on EBP. The facility’s policies required routine cleaning and disinfection of shared equipment, proper use of PPE, and hand hygiene before and after glove use, especially for residents on EBP. These failures were observed despite signage and supplies being available and staff having received training on infection control and EBP requirements.
Failure to Complete Discharge Summaries for Discharged Residents
Penalty
Summary
The facility failed to complete discharge summaries for two residents who were permanently discharged, as required by policy. For one resident, the electronic medical record (EMR) did not contain a discharge summary or a progress note indicating the resident's discharge, despite documentation that the resident was a respite admission under hospice status and was discharged to home or community. The Minimum Data Set (MDS) assessment confirmed the discharge, but the necessary summary and documentation were missing from the record. For the second resident, who had severe cognitive impairment and multiple diagnoses including diabetes, hypertension, and dementia, the nursing progress note indicated discharge with family and hospice assistance, and that medications and a comfort kit were provided. However, the EMR did not contain a discharge summary for this resident either. The MDS assessment confirmed the discharge, but the required summary was not present in the electronic chart. Interviews with facility staff, including the social worker, DON, and administrator, confirmed that the discharge summaries were not completed for these residents. The social worker, who had recently started, was unable to explain the omissions, and the DON acknowledged that the facility had been without a full-time social worker for several months. Facility policy requires an interdisciplinary discharge summary to be completed and included in the closed medical record for all permanent discharges, but this was not done for the two residents in question.
Failure to Promptly Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following a fall. The resident, a female with a history of repeated falls, decreased mobility, legal blindness, and other significant medical conditions, experienced a fall in the bathroom while attempting to pull up her socks. The incident was discovered by a CNA, and the resident was found on the floor with a minor bump on her head. Vital signs were taken, and the family was notified, but the physician was not promptly informed of the incident as required by facility policy. The charge nurse on duty at the time of the fall did not notify the physician until the following day, after being instructed to do so during a morning meeting. The nurse stated she was unaware of the requirement to contact the physician immediately and was not familiar with the facility's fall policy. Interviews with the DON and ADON confirmed that the facility's protocol mandates prompt physician notification after a fall, and that it was the charge nurse's responsibility to do so. Review of the facility's fall management policy corroborated this requirement.
Failure to Timely Change Oxygen Equipment for Resident on Continuous Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident requiring continuous oxygen therapy did not have their oxygen humidification bottle and nasal cannula tubing changed in a timely manner, as required by physician orders and facility policy. The resident, who had a history of stroke, hypertension, pneumonia, and diabetes mellitus, was observed with oxygen equipment that had not been changed or dated according to the weekly schedule. The humidification canister and nasal cannula tubing were last dated over two weeks prior to the observation, and the humidification bottle contained less than a quarter of water. The resident was unable to confirm how often the equipment was changed. Interviews with nursing staff and facility leadership confirmed that the expectation was for oxygen equipment to be changed and dated weekly, specifically on Sunday nights, and that this task was the responsibility of the nursing staff. The facility's policy and physician orders both required weekly changes of the oxygen equipment. Staff acknowledged that failure to change and date the equipment as scheduled could result in lapses in infection control. The deficiency was identified through observation, interviews, and record review.
Failure to Ensure Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to ensure the privacy of a resident during medication administration. On January 1, 2025, LVN A administered insulin to a resident without closing the door or drawing the privacy curtain. This incident was captured on video footage from a Ring camera in the room, which showed the resident in a vulnerable state, wearing only a brief and uncovered from the waist down. The resident, who had a severe cognitive deficit with a BIMS score of 6, was asleep at the time of the incident. The Director of Nursing (DON) confirmed that privacy should have been provided during the administration of care. The facility's policy on patient rights emphasizes maintaining personal dignity and privacy, which was not adhered to in this instance. The DON and the Administrator both acknowledged the importance of respecting residents' privacy during care. The report indicates that the resident and their responsible party were aware of the electronic monitoring in the room and had no concerns about it. However, the failure to provide privacy during the medication administration was a clear violation of the resident's rights as outlined in the facility's policies.
Failure to Timely Report Allegation of Neglect
Penalty
Summary
The facility failed to provide evidence that all alleged violations were thoroughly investigated and reported to the state agency within the required five working days. An allegation of neglect was made regarding a resident who experienced a witnessed fall on the 2-10 PM shift. The resident, who had moderate cognitive impairment and was under one-to-one observation, did not sustain any injuries from the fall. However, the investigation findings were inconclusive, and the facility did not report the results to the state agency within the stipulated timeframe. The Director of Nursing (DON) and the current Administrator were aware of the incident and reported it to Texas Health and Human Services the day after it occurred. Despite this, the required Provider Investigation Report was not submitted to the state agency within five days, as required by the facility's policy. The previous administrator, who was responsible for ensuring the report was submitted, was suspended and later terminated. The facility's failure to report the findings in a timely manner placed residents at risk of not having their allegations investigated or reviewed promptly by the state survey agency.
Failure to Conduct Immediate Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. A Licensed Vocational Nurse (LVN) did not complete a fall assessment after a resident experienced a witnessed fall. The resident, who had a history of repeated falls and moderate cognitive impairment, was abruptly awakened and asked to stand and use the restroom, leading to her falling face-first on the floor. The incident occurred when the LVN, while disconnecting the resident's IV, instructed the resident to get up and go to the bathroom. The resident, who was initially asleep, was made to sit at the edge of the bed and subsequently fell forward, hitting her head on the floor. Despite the fall, the LVN did not perform an immediate assessment for injuries, vital signs, or range of motion before assisting the resident to the bathroom. The LVN's actions were captured on a Ring camera, which showed that the resident was not assessed for injuries immediately after the fall. The Dietary Aide, who was present in the room for one-on-one observation, was not trained to provide direct care and was unable to prevent the fall. The LVN failed to follow the facility's fall management protocol, which required an immediate assessment of the resident's condition post-fall. The Director of Nursing (DON) later confirmed that the LVN did not conduct a thorough assessment as required, and the LVN was subsequently suspended and terminated following the investigation.
Infection Control Breach by LVN During Medication Administration
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of LVN A while administering medications to two residents. LVN A did not perform hand hygiene or change gloves between administering insulin to one resident and discontinuing IV medication for another resident. This lapse in protocol was observed through video footage captured by a Ring camera in the residents' room, which showed LVN A entering the room with gloves already donned and failing to change them between tasks. Resident #1, a female with moderate cognitive impairment and multiple diagnoses including nontraumatic brain dysfunction and diabetes, was receiving Meropenem intravenously. Resident #2, a female with severe cognitive deficit and similar health conditions, was receiving insulin injections. The failure to change gloves and perform hand hygiene between these tasks was confirmed by both the DON and LVN A, who acknowledged the breach in infection control practices. The DON confirmed that LVN A did not follow the facility's infection control policies, which require hand hygiene and the use of new gloves for each resident interaction. LVN A admitted to being aware of these requirements but failed to adhere to them due to being in a hurry at the end of her shift. This oversight was reported by the responsible party for Resident #1, who provided video evidence to the facility and surveyors.
Failure to Ensure Accessibility of Survey Results
Penalty
Summary
The facility failed to ensure that residents, family members, and legal representatives had easy access to view the nursing home's survey results. During a confidential group meeting, residents revealed they were unaware of the location of the Federal or State survey results and their right to review them. The Activities Director was unsure of the exact location of the survey results and stated that he was responsible for informing residents of their rights during resident council meetings. The Administrator indicated that the survey results were temporarily on his desk and usually stored in a drawer in the lobby marked with a Facility Postings and Survey Results sticker. However, there was a lack of communication to residents about the location of these results. The facility's Social Services Policies and Procedures indicated that the leadership should provide a written description of the residents' legal rights, including access to state survey results. Despite this policy, the facility did not ensure that the survey results were placed in a readily accessible location or that residents were informed of their right to view these results. This oversight could lead to a lack of awareness among residents, visitors, and family members regarding the survey results and the facility's plan of correction.
Failure to Investigate Allegations of Neglect
Penalty
Summary
The facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for two residents. Resident #370, a cognitively intact female with a history of falls, experienced an unwitnessed fall resulting in a left pelvis fracture. Despite a self-report being made regarding the fall, no investigation was conducted, and staff members were not questioned about the incident. The facility's accident report and hospital discharge report confirmed the fall and subsequent injury, but there was no documentation of an investigation being carried out by the facility's administration or nursing staff. Resident #270, a cognitively intact male requiring extensive assistance with ADLs, had an allegation of neglect reported by a family member. The family member claimed that the resident's bed was soiled with feces, prompting them to move the resident to a new facility. Although a self-report was made regarding this allegation, there was no provider incident report or documentation of an investigation. Interviews with the current DON and Facility Administrator revealed that they were unaware of any investigations being conducted for these incidents and could not locate any related documentation. The facility's policy mandates that all incidents be investigated promptly and comprehensively, with findings reported to enforcement agencies within five working days. However, the facility failed to adhere to this policy for both residents. The lack of investigation into these allegations of neglect could potentially place residents at risk for further incidents and decreased quality of care. The Corporate Executive Director confirmed that the previous Administrator may not have completed the required investigations, and no documentation was found to support that any investigations were conducted.
Failure to Implement Comprehensive Care Plan for Resident's Food Storage
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #370, who was observed keeping food in her room in unsanitary conditions. Resident #370, a cognitively intact female with multiple diagnoses including diabetes, cancer, end-stage renal disease, and dysphagia, was found with uncovered fresh produce in her room, attracting fruit flies. Despite the resident's impaired vision and preference for family-brought food, the care plan did not address the storage of fresh produce, leading to potential health risks. Interviews with staff revealed that they were aware of the issue but had not included it in the care plan, resulting in a lack of coordinated care and increased infection risk for the resident. The MDS Coordinator and DON were unaware of the extent of the issue, and the care plan had not been updated to reflect the resident's needs for sanitary food storage. Staff members, including an LVN, CNA, and MA, confirmed that the resident frequently received fresh produce from her family and stored it improperly. The facility's policy on person-centered care planning was not followed, as the care plan did not include instructions for managing the resident's food storage habits, leading to a deficiency in providing individualized care and services to meet the resident's needs.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #59, a male with dementia, muscle wasting, and cognitive communication deficit, required maximal assistance with toileting and personal hygiene. During an observation, it was noted that Resident #59 had long, discolored fingernails with dark brown residue. Interviews with staff revealed that CNAs were responsible for trimming nails of non-diabetic residents, while nurses handled diabetic residents. However, the CNA had not noticed the condition of Resident #59's nails that morning, and the DON confirmed that nail care should be completed as needed and observed daily. The facility's policy on activities of daily living indicated that necessary care should be provided to ensure residents maintain proper grooming and hygiene. Despite this policy, the staff failed to ensure Resident #59's nails were cleaned and trimmed, which could pose an infection control issue. The DON stated that routine rounds by the ADON and DON were expected to monitor such issues, but this was not effectively carried out in the case of Resident #59.
Improper Perineal Care Leading to Risk of Infection
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, CNA A did not provide proper perineal care for a resident after an incontinent episode. The CNA cleaned the resident's buttock area from back to front, which is against proper hygiene practices, and did not change gloves or perform hand hygiene when moving from dirty to clean tasks. This improper technique was acknowledged by CNA A during an interview, where she admitted to knowing the correct procedure but failing to follow it. The resident involved was a male with diagnoses including dementia, muscle wasting and atrophy, and cognitive communication deficit. His care plan indicated he required maximal assistance with toileting and personal hygiene. The Director of Nursing (DON) confirmed that the correct procedure for providing incontinent care is to clean from front to back and that failing to do so places residents at risk for infections and skin breakdown. The facility's policy on perineal and incontinent care did not address the specific concern observed.
Failure to Ensure Secure Medication Storage
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals. Specifically, the facility did not ensure that medications in unsecure containers were removed from the Med Aide Cart. During an observation and record review, it was found that a blister pack for a controlled medication used for pain had a broken seal with the pill still inside and taped over. The Med Aide responsible for the cart was unaware of when the blister pack seal was broken or who might have damaged it. The Med Aide acknowledged the risk of potential drug diversion and stated that the nurses and med aides were responsible for checking the medication blister packs during the count of narcotics at shift change, but she did not notice the broken blister during the count. The Director of Nursing (DON) stated that if a blister pack medication seal was broken, the pill should be discarded, and it would not be acceptable to keep a pill in an opened blister pack. The DON highlighted the risks of potential drug diversion and infection control issues. The facility's policy on Medication Storage indicated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures should be immediately removed from stock and disposed of according to procedures for medication destruction. The policy also stated that replacements should be reordered from the pharmacy if needed.
Infection Control Failures
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents. For Resident #59, a CNA did not perform hand hygiene or change gloves during incontinence care. The CNA used the same gloves to remove a soiled brief and place a clean one, and did not clean from front to back as required. The CNA acknowledged the failure to follow proper procedures, which exposed the resident to potential infections. For Resident #46, an LVN did not perform hand hygiene after conducting a finger stick blood sugar (FSBS) test and cleaning the glucometer. The LVN used the same gloves to handle the medication cart and administer insulin without sanitizing hands in between. The LVN admitted to realizing the mistake and acknowledged the risk of cross-contamination and infection. The Director of Nursing confirmed that staff are expected to sanitize their hands when transitioning from dirty to clean tasks.
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.
