Countryview Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Terrell, Texas.
- Location
- 1900 N Frances St, Terrell, Texas 75160
- CMS Provider Number
- 675105
- Inspections on file
- 32
- Latest survey
- August 15, 2025
- Citations (last 12 mo.)
- 23 (1 serious)
Citation history
Health deficiencies cited at Countryview Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not notify residents or their representatives on how to file grievances anonymously, and grievance forms or submission containers were not available in common areas. Residents were unaware of the process, and staff interviews revealed confusion about grievance procedures and the identity of the Grievance Official. The facility's policy required prominent postings and notification, but these were not implemented.
A deficiency was cited when a facility area was not kept free from accident hazards and adequate supervision was not provided to prevent accidents, resulting in an unsafe environment for residents.
Surveyors found that two opened insulin pens, Lantus 100 unit/ml and Insulin pro 100 units/ml, were stored in a medication cart without patient labels or open dates. An LVN confirmed that nurses are responsible for ensuring all insulin pens and vials are labeled and dated, and the DON stated that all insulin should be labeled and dated upon opening. The facility's policy requires proper storage and immediate removal of improperly labeled medications, but audits of medication carts were not performed on a set schedule.
Surveyors found that a dented can was improperly stored with other canned goods instead of being separated for return, and a dietary staff member was observed not fully covering their hair with a restraint during food preparation. The Dietary Manager confirmed these practices, and facility policy did not address dented can handling.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A deficiency was identified when an LVN did not wear required PPE while providing high-contact care to a resident on enhanced barrier precautions due to an indwelling feeding tube. The LVN, despite recent training and awareness of the resident's status, performed medication administration and tube feeding activities without donning gloves and gown, contrary to facility policy and infection control protocols.
A CNA physically abused a resident by grabbing and twisting her arm and choking her, resulting in visible injuries and emotional distress. The resident, who has a history of trauma and cognitive impairment, was able to communicate the details of the incident, which was corroborated by another CNA and a resident. The facility failed to ensure all staff were trained in abuse prevention and behavior management, contributing to the deficiency.
The facility failed to provide palatable and appropriately heated meals, as observed during a lunch meal. Residents reported dissatisfaction with the food's taste and temperature, with some meals being cold or burnt. The Dietary Manager, new to the role, was unaware of specific temperature requirements and had not conducted training on food quality. The Administrator was aware of past complaints but had not recently verified food quality through test trays. The facility's policy did not address food palatability or temperature, contributing to the deficiency.
The facility experienced delays in meal service due to insufficient staffing in the dietary department, with meals often served late. Residents expressed dissatisfaction, and the Dietary Manager cited issues with nursing staff availability as a contributing factor. The Administrator acknowledged the problem but had not implemented corrective actions.
The facility failed to follow professional standards for food service safety, with numerous food items in the kitchen freezer and refrigerator found unlabeled and undated, and expired items not disposed of. Dented cans were improperly stored, and the deep fryer was unclean. Interviews revealed inadequate oversight and training, with the Dietary Manager and Administrator acknowledging lapses in regular inspections and in-service training.
The facility failed to provide consistent dialysis care for two residents, as evidenced by missing communication forms and incomplete post-dialysis assessments. One resident with end-stage renal disease and another with chronic kidney disease experienced lapses in documentation, including vital signs and blood pressure records. Staff interviews confirmed the importance of completing dialysis communication forms to ensure continuity of care and monitor potential issues.
The facility failed to maintain an effective infection prevention and control program, impacting residents and staff. Issues included improper hand hygiene, lack of PPE use, and inadequate catheter and wound care, increasing the risk of infection.
A resident with quadriplegia and other muscle-related conditions suffered a third-degree burn from spilled coffee, which was not reported to the state agency as required by the facility's policies. The incident was not documented in the state agency reporting system, and the facility's failure to adhere to its abuse and neglect policy could place residents at risk for further harm.
A resident with quadriplegia sustained a severe coffee burn to his thigh, which was not reported to the State Survey Agency within the required two-hour timeframe. Despite the resident's care plan indicating a risk for burns, the incident was not documented in the facility's incident report system. Interviews with staff revealed a lack of documentation and oversight, leading to the failure to report the incident as mandated by the facility's abuse policy.
A facility failed to involve a resident and her representative in care planning, leading to missed care plan meetings and lack of documentation. The resident, with severe cognitive impairment, was not included in meetings, and her family expressed concerns about care management. The MDS Nurse admitted to inconsistent notifications and documentation, while facility leaders highlighted the importance of family involvement.
A facility failed to ensure privacy for a resident during wound care, as an LVN left the door open and did not pull the curtain, exposing the resident. The resident, who required assistance with personal care, was cognitively intact and expressed discomfort with the lack of privacy. Interviews with facility staff confirmed the expectation to maintain privacy, aligning with the facility's policy on respect and dignity.
The facility failed to provide meaningful activities for its residents, as evidenced by the lack of quarterly activity assessments and the absence of scheduled activities. A resident with chronic kidney disease expressed boredom and dissatisfaction with limited activities, while another resident with COPD and lung cancer reported a lack of meaningful engagement. The Activity Director admitted to not assessing or documenting residents' participation, citing being frequently pulled to assist in other departments. Residents expressed dissatisfaction with the activity program, noting the absence of outings and social events.
A resident with multiple sclerosis, major depressive disorder, and dementia was found keeping cigarettes in her purse and smoking outside designated areas, contrary to facility policy. A CNA was also observed smoking with the resident outside the designated area, acknowledging the violation. Facility staff confirmed the resident's non-compliance and the responsibility of staff to enforce the smoking policy. The administrator expressed concerns about potential fire risks due to the resident's actions.
A resident with an indwelling catheter did not receive proper incontinent care, as a CNA failed to perform hand hygiene and catheter care, increasing the risk of urinary tract infections. The resident, dependent on others for toileting hygiene, was observed during care where the CNA did not change gloves or wash hands between dirty and clean tasks. Staff members acknowledged the oversight but did not intervene, and the facility's policies on hand hygiene and perineal care were not followed.
A facility failed to monitor a resident's fluid intake, who was on a 1-liter fluid restriction due to chronic kidney disease and dialysis dependence. The care plan did not address the restriction, and the medication administration record lacked documentation of fluid intake. Staff interviews revealed a lack of awareness and monitoring, with the resident having access to more fluids than allowed. The facility's policy required strict monitoring, which was not followed.
A facility failed to properly store a nebulizer mask for a resident with COPD, leaving it uncovered on a bedside table. The resident required nebulizer treatments for shortness of breath, and the mask should have been stored in a bag when not in use to prevent infection. The charge nurse admitted to not following proper storage protocols, and the facility's policy did not address equipment storage, leading to this oversight.
A facility failed to ensure LVNs had the necessary IV therapy certification, leading to uncertified nurses administering IV therapy to a resident with multiple health conditions. The oversight was due to the newness of the DON and ADON in their roles, who were responsible for verifying certifications.
A resident did not receive two doses of methocarbamol for muscle spasms due to the medication not being available. The nursing staff failed to reorder the medication in a timely manner, and the facility's policy did not address ensuring medication availability. Interviews with staff confirmed the oversight, which could lead to the resident experiencing pain.
The facility failed to follow the approved menu for a lunch meal, serving unapproved substitutions without notifying the dietician or administrator. The dietary manager, new to her role, did not contact the dietician over the weekend for approval, as required by policy. The administrator was unaware of the menu changes and the dietician's unavailability on weekends. This failure to adhere to the menu policy could affect all residents by not meeting their nutritional needs.
A resident was not provided with his preferred beverage, cranberry juice, and was instead served iced tea, which he disliked. Despite clear instructions on his tray card, the facility staff failed to ensure his preferences were honored, potentially leading to dehydration. Interviews with staff revealed a lack of adherence to the facility's policy on honoring resident preferences.
Two residents with severe cognitive impairment did not receive the large protein portions prescribed by their physicians. One resident did not receive a large meat portion for lunch, and another did not receive a large sausage portion for breakfast. Staff interviews confirmed the expectation to follow physician orders and tray cards, but the protocol was not effectively implemented, leading to the deficiency.
A resident with a non-healing sore on her back did not have a dermatology appointment scheduled despite an existing order. The resident, who was cognitively intact, had requested the appointment multiple times. Interviews with staff revealed a lack of awareness and follow-through on the order, and the resident's care plan did not address the necessary referral.
The facility failed to coordinate hospice care for two residents, resulting in outdated hospice plans and mismatched medication regimens. Interviews revealed a lack of communication and collaboration between facility staff and hospice representatives, leading to inadequate documentation and care coordination.
A resident with dementia and other medical conditions repeatedly expressed a desire to leave the facility and made several attempts to do so. Despite this, the facility did not implement adequate interventions to prevent elopement, resulting in the resident leaving the facility and being found in a nearby shopping center. The facility failed to follow its elopement prevention policy and did not update the resident's care plan with appropriate interventions.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Anonymous Grievance Process and Notification
Penalty
Summary
The facility failed to notify residents or their representatives on how to file a grievance or complaint in an anonymous manner. During a confidential Resident Council interview with six residents, it was revealed that the residents were unaware of the location of grievance forms and did not know how to file a grievance anonymously. Observations of the facility's common areas confirmed that there were no grievance forms or containers available for submitting grievances. The Activities Director stated that she was the primary person with access to grievance forms and was unsure where else residents could obtain them. If the Activities Director was unavailable, residents could turn in forms to the head nurse, but there was no clear process for anonymous submission. Further interviews with the DON indicated that grievances were filled out in the electronic medical record (EMR), and the Activities Director distributed and assisted with the forms, which were then given to unspecified staff for entry into the EMR. The DON was not aware of who the designated Grievance Official was or the specific process for submitting grievances. Review of the facility's grievance policy showed that residents should be notified on how to file grievances orally, in writing, or anonymously, with postings in prominent locations, but these procedures were not being followed.
Failure to Maintain a Hazard-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the occurrence of accidents. The deficiency centers on the lack of appropriate measures to identify and eliminate hazards, as well as insufficient oversight to safeguard residents from potential harm.
Failure to Label and Date Opened Insulin Pens in Medication Cart
Penalty
Summary
Surveyors observed that the facility failed to properly label and date opened insulin pens stored in one of its medication carts. Specifically, two opened insulin pens, Lantus 100 unit/ml and Insulin pro 100 units/ml, were found without patient labels or dates indicating when they were opened. This was identified during an observation of the 600-hall medication cart. During interviews, a nurse confirmed that it was the responsibility of nursing staff to ensure all insulin pens and vials had patient labels and open dates, and acknowledged that the pens in question were not labeled or dated as required. Further interviews with the Director of Nursing (DON) confirmed that all insulin pens and vials should be labeled and dated upon opening, as insulin expires 28 days after being opened. The DON stated that it was the responsibility of every nurse to check for proper labeling and dating before administering insulin. The facility's policy also requires that medications be stored safely and properly, and that outdated or improperly labeled medications be immediately removed. However, the audit process for medication carts was not conducted on a set schedule, and the pharmacist only audited the carts monthly.
Deficient Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial kitchen tour, a dented can was observed stored on the rack with other canned items in the dry storage area, rather than in the designated area labeled for dented cans not to be used. The Dietary Manager confirmed that dented cans were used first and repeated this practice during the interview. The facility's policy on food storage and supplies did not address the handling of dented cans, and the U.S. Department of Health and Human Services Food Code requires food packages to be in good condition to protect the integrity of the contents. Additionally, a dietary staff member was observed not properly using a hair restraint to cover all hair during food preparation. The Dietary Manager acknowledged that improper use of hair restraints could result in food contamination. Interviews with dietary staff confirmed that dented cans should not be used due to the risk of contamination and that proper hair restraint is necessary to prevent biological contaminants from entering food.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to don personal protective equipment (PPE) prior to performing high-contact care activities for a resident on enhanced barrier precautions. The resident, a male with a history of cerebrovascular accident and dysphagia requiring tube feeding, was identified as being on enhanced barrier precautions due to the presence of an indwelling medical device. Facility policy required staff to wear gloves and gowns during high-contact activities such as medication administration via feeding tube, but the LVN only performed hand hygiene and did not use the required PPE while stopping the tube feeding, administering medication, and restarting the feeding. The LVN acknowledged awareness of the resident's precaution status and the need for PPE, stating she had received recent in-service training on enhanced barrier precautions. The Director of Nursing (DON) confirmed that staff were expected to use appropriate PPE for residents on enhanced barrier precautions and that staff had been trained on these protocols. Facility policy outlined the necessity of PPE use to prevent the transmission of multidrug-resistant organisms (MDROs) during high-contact care for residents with indwelling medical devices.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A certified nursing assistant (CNA) physically abused a resident by grabbing and twisting the resident's arm and then placing her hands on the resident's neck and choking her. The incident was witnessed by another CNA and a resident, both of whom confirmed that the CNA grabbed the resident's arm, twisted it, and choked her. The resident, who has a history of trauma related to domestic abuse and physical assault, was left with visible injuries including scratches, bruising, and red marks on her arm and neck. The resident was observed to be upset and tearful following the incident, and her injuries were documented by multiple staff members. The resident involved had significant medical and psychological conditions, including hemiplegia, hemiparesis, vascular dementia, bipolar disorder, and anxiety disorder. She had moderate cognitive impairment but was usually able to make herself understood. Her care plan included trauma-informed interventions and communication support due to expressive aphasia. At the time of the incident, the resident was able to communicate through gestures and yes/no responses, confirming the details of the abuse and identifying witnesses. The incident was corroborated by physical evidence and multiple staff and resident interviews. The facility failed to ensure the resident's right to be free from abuse and neglect, as required by policy and regulation. The CNA's actions constituted willful physical abuse, resulting in physical harm and emotional distress to the resident. The deficiency was further compounded by the fact that not all staff had been trained on behavior management procedures, abuse prevention, and trauma-informed care plans at the time of the incident, which could place other residents at risk of harm.
Removal Plan
- Review completed facility self-reported incident to HHSC for Resident #1
- Interview Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 to confirm no other residents had been abused and that they enjoyed the facility staff
- Suspend CNA A pending completion of investigation into allegations of abuse
- Terminate CNA A after substantiating the allegation of abuse
- Verify CNA A had a criminal history check before hire
- Report the incident between CNA A and Resident #1 to the local police department
- Conduct safe survey resident interviews to confirm no other residents complained of abuse/neglect or misappropriation and that residents felt safe
- Provide in-service education on abuse and neglect to facility staff
- Provide in-service education on behavior management to facility staff
- Interview staff to confirm understanding of abuse, reporting procedures, behavior management, and de-escalation techniques
- Complete a trauma assessment for Resident #1 by the MDS Coordinator
- Add Resident #1 to psych services and ensure a provider visit
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for one of the three meals reviewed. This deficiency was observed during a lunch meal on 7/29/24, where the food served was not at the appropriate temperature, and residents reported dissatisfaction with the taste and quality of the meals. Several residents expressed concerns about the food being cold, burnt, or overly seasoned, and noted that alternatives were not offered as they had been in the past. The Dietary Manager, who had been employed for two weeks, acknowledged the issues with food temperature and palatability. She stated that she was responsible for ensuring the food was served correctly but was unaware of the specific temperature requirements for hot foods. The Dietary Manager also mentioned that meals sometimes sat on carts for extended periods before being delivered to residents' rooms, contributing to the temperature issues. Despite receiving complaints about cold food, the Dietary Manager had not conducted any in-services on maintaining food quality and temperature. The Administrator, employed since May 2024, was aware of past complaints about food being cold but had not received any recent complaints. He expected the dietary staff to ensure food quality but had not requested test trays to verify the food's palatability and temperature. The facility's policy on resident menus did not address the importance of palatability, attractiveness, or food temperatures, which may have contributed to the oversight in maintaining food quality standards.
Meal Service Delays Due to Staffing Issues
Penalty
Summary
The facility failed to provide sufficient staff to effectively conduct food and nutrition services, resulting in meals not being served at the posted times in the main dining room. Observations and interviews revealed that the breakfast and lunch meals were consistently served late, with residents experiencing delays in receiving their meals. On one occasion, only one dietary aide was present in the dining room, and the Dietary Manager was absent, reportedly at the grocery store. This lack of staffing contributed to the delays in meal service. Residents expressed dissatisfaction with the late meal service, noting that lunch was often served late, although breakfast was usually on time. On one occasion, a resident's breakfast tray was missing, causing further frustration. The dietary staff reported that they were ready to serve breakfast on time, but delays occurred due to nursing staff being occupied with other tasks, such as completing medication passes. The Dietary Manager acknowledged the issues with meal service timing and reported that nursing staff often delayed meal service by not being available to check trays promptly. The Administrator and ADON were aware of the issues with meal service timing but had not implemented in-services or corrective actions to address the problem. The Administrator noted that dietary staff sometimes had to leave the facility to purchase meal items, causing further delays. The facility's policy emphasized the importance of serving meals and snacks in a timely manner, but this was not consistently achieved, leading to resident dissatisfaction and potential risks associated with delayed meal service.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and dietary services. Numerous food items in the kitchen freezer were found without proper labeling, including missing receive dates, open dates, and expiration dates. This included various frozen foods such as yellow squash, ice cream, and chicken nuggets, among others. Additionally, expired food items were not disposed of, and some food items were not properly sealed, increasing the risk of contamination. In the kitchen refrigerator, similar issues were noted with unlabeled and undated thawed lunch meats and other food items. The dry storage area also contained dented cans stored improperly, and expired seasoning bottles were not discarded. Furthermore, a scoop was found inside a sugar container, which is against the facility's dietary policy. The deep fryer was observed to be unclean, with black grease and bread crumbs floating inside, indicating a lack of regular maintenance. Interviews with the dietary staff revealed a lack of consistent oversight and training. The Dietary Manager, who had been in the position for only two weeks, admitted to not conducting daily walk-throughs and acknowledged the need for more frequent inspections. The Administrator claimed to conduct weekly inspections but had not recently provided in-service training on fryer use and cleaning. The facility's dietary policy from 2012 outlines proper food storage and handling procedures, which were not being followed, leading to potential health risks for residents.
Deficiency in Dialysis Care Documentation
Penalty
Summary
The facility failed to ensure that residents requiring dialysis services received care consistent with professional standards of practice. This deficiency was identified for two residents who were reviewed for dialysis services. The facility did not maintain ongoing communication with the dialysis facility for these residents, which could place them at risk for complications and inadequate care. For one resident, the facility's records showed missing dialysis communication forms on several dates in July 2024, and there was a lack of post-dialysis vital sign documentation on multiple occasions. This resident had a history of end-stage renal disease, type 2 diabetes mellitus with diabetic neuropathy, and encephalopathy. Despite having a moderate cognitive impairment, the resident was able to communicate and understand others, as indicated by their MDS assessment. Another resident, who had chronic kidney disease, dependence on renal dialysis, and heart failure, also experienced deficiencies in dialysis care. The facility's documentation revealed incomplete post-dialysis assessments and missing blood pressure records on several dates in July 2024. Interviews with facility staff, including an LVN, ADON, RNC, and the Administrator, confirmed that the dialysis communication forms were not consistently completed, which was crucial for ensuring continuity of care and monitoring potential issues such as hypotension.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, impacting both residents and staff. LVN A did not ensure that a resident's PICC line had the proper cap to prevent infection, and failed to perform hand hygiene while administering medications to two residents. Additionally, enhanced barrier precautions were not in place for a resident, increasing the risk of infection. LVN C improperly stored a urine specimen, which could lead to cross-contamination. CNA L did not perform hand hygiene during a resident's continent care and failed to provide catheter care. LVN K did not clean and treat a resident's pressure wounds individually and did not perform hand hygiene during wound care. Furthermore, LVN K improperly handled soiled linen, which could contribute to the spread of infection. CNA B and CNA O did not don PPE before entering a resident's room and failed to perform hand hygiene after removing gloves during incontinent care. CNA B also neglected to sanitize hands between delivering meal trays to residents, which could lead to cross-contamination. The facility's failure to adhere to infection control practices and transmission-based precautions placed residents at increased risk for serious complications from communicable diseases, potentially diminishing their quality of life.
Failure to Report and Prevent Resident Burn Incident
Penalty
Summary
The facility failed to implement its policies and procedures to prevent abuse, neglect, and exploitation of residents, as evidenced by the incident involving a resident who sustained a severe coffee burn. The resident, who had a history of heart failure, quadriplegia, and other muscle-related conditions, was at risk for burns due to hot liquids. Despite this risk being noted in the resident's care plan, the facility did not adhere to the necessary precautions, resulting in the resident suffering a third-degree burn on the right thigh from spilled coffee. The incident was not reported to the state agency as required by the facility's abuse and neglect policy. The policy mandates that any allegations of abuse or incidents resulting in serious bodily injury must be reported within two hours. However, the burn incident involving the resident was not reported to the Health and Human Services Commission (HHSC) within the specified timeframe, nor was it documented in the state agency reporting system for abuse and neglect. This oversight was acknowledged by the Assistant Director of Nursing (ADON), the Registered Nurse Consultant (RNC), and the Administrator, all of whom were not employed at the facility at the time of the incident. The lack of timely reporting and documentation of the incident could potentially place residents at risk for further abuse, neglect, and injuries of unknown origin. The facility's failure to follow its own policies and procedures for reporting and investigating such incidents highlights a significant deficiency in ensuring resident safety and compliance with regulatory requirements.
Failure to Report Resident Burn Incident Timely
Penalty
Summary
The facility failed to report an incident involving a resident who sustained a severe coffee burn to his right thigh. The incident was not reported to the State Survey Agency within the required two-hour timeframe after the facility became aware of the injury. This failure involved a resident who was at risk for burns due to hot liquids, as indicated in his Comprehensive Care Plan. The resident, who had no cognitive deficits, reported the burn to a nurse, who documented the injury and initiated treatment. However, the incident was not reported to the state agency as required. The resident, a male with a history of heart failure, quadriplegia, and other conditions, experienced a burn when a coffee cup spilled on him while he was trying to sit up. The injury was initially assessed by a nurse and later by a nurse practitioner, who documented the burn as a third-degree injury with significant tissue damage. Despite the severity of the injury, the incident was not documented in the facility's incident report system, nor was it reported to the state agency within the mandated timeframe. Interviews with facility staff, including the ADON, RNC, and Administrator, revealed that the incident was not reported due to a lack of documentation and oversight. The facility's abuse policy required such incidents to be reported within two hours, but this protocol was not followed. The failure to report the incident in a timely manner could have delayed the necessary care and services for the resident, as acknowledged by the facility's current Administrator.
Failure to Involve Resident and Family in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were involved in the development and implementation of her person-centered care plan. The resident, who has severe cognitive impairment due to dementia, cerebrovascular disease, heart failure, and high blood pressure, was not included in care plan meetings on two occasions. On one occasion, the resident's representative attended the meeting, but the resident did not want to attend. On another occasion, the resident attended, but her representative was not reached, and there was no documentation of attempts to contact her. Interviews revealed that the resident's family member had been requesting a care plan meeting since the resident's admission, but was told by a nurse that the facility was behind schedule. The family member expressed concern about the resident's discharge from hospice services and her ability to manage care. The hospice nurse confirmed that the family had reached out with concerns about the lack of care plan meetings and was told by the facility that such meetings did not occur. The MDS Nurse, responsible for care plan meetings, admitted to inconsistencies in notifying families and documenting these notifications. She acknowledged that the resident's family was difficult to contact and that she had not documented attempts to reach them. The ADON and DON emphasized the importance of care plan meetings for resident and family involvement, while the Administrator noted the risk of families being unaware of care changes due to lack of documentation.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to protect and promote the rights of a resident by not ensuring privacy during wound care. A Licensed Vocational Nurse (LVN) provided wound care to a resident without closing the door or pulling the curtain, leaving the resident exposed. The resident, a female with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and lung cancer, was cognitively intact and required assistance with personal care. The LVN admitted to forgetting to ensure privacy, acknowledging that anyone could have walked in and seen the resident undressed. Interviews with the Assistant Director of Nursing (ADON), the Regional Corporate Compliance Nurse, and the Administrator confirmed that the expectation was for staff to maintain privacy by closing doors and pulling curtains during care. The facility's policy on respect and dignity also required privacy to be maintained. The failure to provide privacy during care was identified as a dignity and privacy issue, with the responsibility for ensuring privacy resting on the staff providing care and the management overseeing them.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the interests and needs of its residents, as evidenced by the lack of quarterly activity assessments for several residents, including Resident #24 and Resident #27. Resident #24, a 63-year-old male with chronic kidney disease and heart failure, expressed boredom and dissatisfaction with the limited activities available, such as bingo and dominoes. Despite a care plan indicating the need for social and mental stimulation, Resident #24 reported that requests for more varied activities and outings had not been addressed. Observations confirmed that scheduled activities were not consistently conducted, and the Activity Director admitted to not assessing or documenting residents' activity participation. Resident #27, a female with chronic obstructive pulmonary disease and lung cancer, also experienced a lack of meaningful activities. She reported that the only activity provided was by a volunteer on Tuesday evenings, and outings that were previously scheduled had been canceled. The Activity Director acknowledged the failure to document activity assessments and participation, citing being frequently pulled to assist in other departments as a reason for the oversight. This lack of documentation and follow-through on scheduled activities contributed to the residents' dissatisfaction and unmet needs. Interviews with other residents revealed a general dissatisfaction with the activity program, describing it as inadequate and likening their experience to being in prison. They noted the absence of outings and social events that were previously part of the program. The facility's policy on activity programming emphasized the importance of activities based on residents' interests and needs, yet this was not reflected in practice. The Administrator and other staff members recognized the importance of meaningful activities but were unaware of the residents' concerns, indicating a disconnect between policy and implementation.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards and provide adequate supervision to prevent accidents for a resident. The resident, who had multiple sclerosis, major depressive disorder, and dementia, was observed keeping cigarettes in her purse and smoking outside designated areas. Despite the facility's policy requiring smoking materials to be stored at the nurse's station and smoking to occur only in designated areas, the resident did not comply, citing concerns about her cigarettes and lighter going missing. A Certified Nursing Assistant (CNA) was also observed smoking with the resident outside the designated smoking area, acknowledging the violation of facility rules. The CNA admitted to being aware of the policy but cited personal stress as a reason for the lapse in judgment. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Regional Corporate Compliance Nurse, confirmed that the resident was non-compliant with the smoking policy and that staff were responsible for ensuring compliance. The facility's administrator expressed concerns about the potential risks posed by the resident's non-compliance, including the possibility of fires. The administrator had previously confiscated cigarettes and lighters from the resident, who would subsequently acquire more. The facility's smoking policy, revised in 2017, clearly stated that smoking materials should not be kept in resident rooms and that smoking was only permitted in designated areas.
Inadequate Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to a risk of urinary tract infections. The resident, a female with rheumatoid arthritis, a fractured right femur, and multiple pressure ulcers, was dependent on others for toileting hygiene and had an indwelling catheter. The care plan required catheter care every shift, but during an observation, a CNA did not perform catheter care while providing incontinent care. The CNA, identified as L, did not perform hand hygiene between handling dirty and clean areas during the incontinent care process. This was observed by other staff members, including an RN and an LVN, who acknowledged the oversight but were unaware they could intervene to correct the procedure. The CNA admitted to forgetting to perform hand hygiene and believed she had completed catheter care, which was not the case. Interviews with the ADON, RNC, and the Administrator revealed expectations for staff to perform hand hygiene between clean and dirty tasks to prevent infections. The facility's policies on hand hygiene and perineal care were not followed, as the CNA did not change gloves or wash hands appropriately, increasing the risk of infection for the resident.
Failure to Monitor Fluid Restriction for Resident
Penalty
Summary
The facility failed to ensure that a resident with a fluid restriction was properly monitored for fluid intake, which could place the resident at risk for dehydration. The resident, a 63-year-old male with chronic kidney disease, dependence on renal dialysis, and heart failure, was on a 1-liter fluid restriction. Despite this, the care plan did not address the fluid restriction, and the medication administration record lacked numerical entries indicating the amount of fluids consumed by the resident. Observations revealed that the resident had access to a water pitcher with 500 milliliters of ice water and reported drinking more than the restricted amount daily, without being asked by staff about his fluid intake. Interviews with facility staff, including an LVN, the Dietary Manager, the ADON, the RNC, and the Administrator, revealed a lack of awareness and monitoring of the resident's fluid restriction. The LVN was unsure of the specific fluid restriction amount, and the Dietary Manager was unaware of the restriction altogether. The ADON acknowledged that the check marks on the medication administration record did not constitute proper monitoring, and the RNC and Administrator both emphasized the importance of following physician orders for fluid restrictions. The facility's Dialysis Policy required strict intake and output monitoring, which was not adhered to in this case.
Improper Storage of Nebulizer Mask
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident with chronic obstructive pulmonary disease, diabetes mellitus, and essential hypertension. The resident, who was severely cognitively impaired, required nebulizer treatments as needed for shortness of breath and wheezing. Observations revealed that the resident's nebulizer mask was repeatedly left uncovered on the bedside table when not in use, contrary to professional standards of practice and infection control protocols. Interviews with the charge nurse and the Regional Corporate Compliance Nurse confirmed that the nebulizer mask should have been stored in a bag when not in use to prevent respiratory infections. The charge nurse admitted to failing to place the nebulizer mask back in its plastic bag after administering treatments. The facility's Medication Administration Procedures policy did not address the storage of plastic equipment, contributing to the oversight. The Administrator acknowledged that these failures could put residents at risk for respiratory infections due to particles accumulating on the mask.
Deficiency in IV Therapy Certification for LVNs
Penalty
Summary
The facility failed to ensure that licensed nurses demonstrated the necessary competencies and skill sets to care for a resident's needs, specifically in administering Intravenous (IV) therapy. Three Licensed Vocational Nurses (LVN A, LVN C, and LVN H) provided IV therapy to a resident without having the required certification for IV therapy. This deficiency was identified during a survey when the Assistant Director of Nursing (ADON) could not provide documentation proving the LVNs had the necessary certification. The facility's policy mandates that IV medications be administered only by IV-certified LVNs or RNs, which was not adhered to in this case. The resident involved was an elderly female with multiple health conditions, including acute and chronic respiratory failure, diabetes mellitus type 2, hypertension, peripheral vascular disease, and bacteremia. She required IV access for antibiotics. The failure to ensure proper certification for IV therapy placed the resident at risk of receiving incorrect IV administration. Interviews with the ADON, Regional Corporate Compliance Nurse, and the Administrator revealed that the responsibility for ensuring certifications were completed and up-to-date fell on the DON and ADON. However, both were relatively new to their positions, contributing to the oversight.
Failure to Ensure Availability of Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in ensuring the availability of methocarbamol, a medication prescribed for muscle spasms. On 7/29/2024, the resident did not receive two of the three scheduled doses of methocarbamol due to the medication not being available. The resident, who was cognitively intact with a BIMS score of 15, reported not receiving the medication when he inquired with the nurse. The nurse confirmed that the medication was not available and had been reordered on the same day. Interviews with the nursing staff, including an LVN, the ADON, and the RNC, revealed that the responsibility for reordering medications in a timely manner fell on the nursing staff. The facility's Medication Administration Procedures policy did not address ensuring the availability of medications, contributing to the oversight. The lack of methocarbamol could lead to the resident experiencing pain from muscle spasms, as noted by the staff during interviews.
Failure to Follow Approved Menu for Resident Meals
Penalty
Summary
The facility failed to ensure that the meals served met the nutritional needs of residents during a lunch meal. On the specified date, the facility did not follow the planned menu, serving chicken fried steak instead of chicken fried chicken, cream corn instead of Mexicali corn, and cantaloupe instead of banana pudding with wafers. This deviation from the menu was not approved by the dietician, as required by the facility's policy. The dietician, who had been in her role for four years, stated that she was not informed of the menu changes by the dietary manager, who had been in her position for only two weeks. The dietary manager did not contact the dietician over the weekend to approve the substitutions, as the dietician did not work on weekends. The dietary manager also failed to inform the administrator of the menu changes. The administrator, who had been employed since May 2024, was unaware of the dietary staff not following the menu and was not informed of the dietician's unavailability on weekends. The facility's menu policy requires that any meal served that varies from the planned menu must be noted on a substitution log and approved by the dietician. The dietary manager admitted that in-services on meal changes had not been completed with the dietary staff, which contributed to the failure to follow the approved facility menus.
Failure to Provide Resident with Preferred Beverage
Penalty
Summary
The facility failed to provide Resident #17 with drinks consistent with his preferences, specifically cranberry juice with all meals instead of tea. This deficiency was identified during an observation where Resident #17, who has no cognitive deficits and requires assistance with eating, was served iced tea despite his tray card indicating a dislike for tea and a preference for cranberry juice. The Licensed Vocational Nurse (LVN) acknowledged the error and stated that the nurse was responsible for checking meal cards and trays before they were given to residents. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Registered Nurse Coordinator (RNC), and the Administrator, revealed that there was an expectation for residents to receive their preferred beverages. The ADON and RNC both emphasized the importance of following the resident's orders and tray cards, with the RNC noting that the Dietary Manager (DM) was responsible for maintaining the preference list. The Administrator highlighted that dietary staff should set up the tray, and the nurse should verify it before serving, to prevent such errors. The facility's policy on Resident Meal Services and HS Snack outlines the procedure for determining and honoring resident food and beverage preferences. It specifies that upon admission and periodically thereafter, the dietary manager or designee should interview residents to record their preferences on tray cards. Despite this policy, the failure to provide Resident #17 with his preferred beverage of cranberry juice instead of tea was not addressed, potentially leading to dehydration and dissatisfaction.
Failure to Provide Prescribed Large Protein Portions
Penalty
Summary
The facility failed to ensure that residents received and consumed foods with the appropriate nutritive content as prescribed by the physician. Specifically, two residents, both with severe cognitive impairment, did not receive the large protein portions ordered by their physicians. Resident #31, who has dementia, heart failure, and high blood pressure, was observed not receiving a large meat portion on his lunch tray, despite physician orders for a regular textured diet with large protein portions. Similarly, Resident #16, diagnosed with dementia, respiratory failure, and a urinary tract infection, did not receive the large portion of sausage as ordered for breakfast. The deficiency was observed during meal service, where Resident #31's lunch tray did not include the large meat portion as indicated on his tray card. For Resident #16, the breakfast tray included a standard portion of sausage instead of the large portion specified. The MDS nurse confirmed the discrepancy and rectified it by obtaining an additional sausage patty for Resident #16. The facility's policy on meal services indicates that large portions can be ordered and served if requested, but this was not adhered to in these instances. Interviews with facility staff, including the ADON, RNC, and Administrator, revealed an expectation that physician orders and tray cards should be followed to ensure residents receive the necessary nutrition. The staff acknowledged the risk of weight loss when residents do not receive the prescribed large protein portions. The process involves the dietary department setting up trays, nurses checking for accuracy, and CNAs verifying before serving, but this protocol was not effectively implemented, leading to the deficiency.
Failure to Schedule Dermatology Appointment for Resident
Penalty
Summary
The facility failed to arrange an appointment with an outside dermatologist for a resident who had a non-healing sore on her lower mid-back, despite having an order dated several months prior. The resident, who was cognitively intact and required assistance with daily activities, expressed that she had requested to be seen by a dermatologist multiple times but felt the facility had forgotten to complete the process. The resident's comprehensive care plan did not address referrals or appointments with a dermatologist, indicating a lack of follow-through on the necessary medical care. Interviews with facility staff, including the ADON and the Regional Corporate Compliance Nurse, revealed a breakdown in communication and responsibility regarding the scheduling of the appointment. The ADON was unaware of the order for the dermatologist appointment, and the Regional Corporate Compliance Nurse acknowledged that the referral should have been scheduled and completed by this time. The facility's policy on medication reconciliation was not effectively implemented, leading to the oversight of the resident's needed medical care.
Deficient Coordination of Hospice Care
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for two residents, who were receiving hospice care, as the facility did not obtain their most recent hospice plans of care. Additionally, the facility did not ensure that the hospice plans of care accurately reflected the residents' medication regimens, which could lead to inadequate end-of-life care due to a lack of documentation, coordination, and communication of resident needs. For Resident #8, the facility did not have an updated hospice plan of care in the hospice binder, with the last certification dated several months prior. The hospice administration record and the facility's physician orders did not match, with discrepancies noted in the medication orders. Interviews with facility staff and hospice representatives revealed a lack of awareness and communication regarding the current hospice plan of care and medication reconciliation, highlighting the importance of collaboration to ensure residents receive necessary medications and treatments. Similarly, for Resident #12, the facility's records did not match the hospice's medication regimen, and the hospice plan of care was not updated to reflect the current needs of the resident. Interviews with hospice staff and facility management indicated that the hospice plan of care should be provided to the facility after each team meeting, and the medication regimens should be reviewed weekly to ensure accuracy. However, this process was not followed, leading to discrepancies in care coordination and documentation.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure a safe environment for a resident who was at risk of elopement. The resident, who had a history of dementia, stroke, diabetes, and seizures, repeatedly expressed a desire to leave the facility and made several attempts to do so. Despite these behaviors, the facility did not implement adequate interventions to prevent the resident from eloping. On one occasion, the resident managed to leave the facility and was found in a shopping center parking lot, approximately 0.3 miles away. The resident's care plan did not address the risk of elopement until after the incident occurred. Prior to the elopement, the facility's interventions were limited to redirection and discussions about the resident's behavior. The staff failed to complete an elopement assessment or update the care plan with appropriate interventions, such as placing the resident on 1:1 monitoring or applying a wander guard. The facility's policy on elopement prevention was not followed, and there was a lack of documentation regarding the resident's condition and the facility's efforts to prevent elopement. Interviews with staff revealed that they were aware of the resident's attempts to leave and his statements about wanting to leave the facility. However, they did not take these statements seriously and did not implement the necessary interventions to prevent elopement. The facility's failure to address the resident's risk of elopement and to follow its own policies resulted in the resident leaving the facility without staff knowledge, placing him at risk of harm.
Removal Plan
- Resident #1 no longer resides in the facility.
- Elopement risk assessments for all residents in the facility were completed and reviewed by the DON/ADON/Designee. No additional concerns were identified.
- All elopement risk care plan interventions were reviewed by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned.
- The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the following: Elopement Prevention Policy to include implementing interventions for residents at risk, Elopement Response Policy.
- The Medical Director was notified of the immediate jeopardy.
- An additional QAPI meeting was conducted to discuss the immediate jeopardy citation and subsequent plan of correction.
- The Regional Compliance Nurse, Administrator, DON, and ADON will in-service all staff on the following topics: All staff were in-serviced on the elopement response policy by the Compliance Nurse, Administrator and DON, All staff were in-serviced on elopement prevention by the Compliance Nurse, Administrator, and DON.
- Observation of the 400 hall exit door revealed it was repaired.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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