Estates Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 201 Sycamore School Rd, Fort Worth, Texas 76134
- CMS Provider Number
- 675028
- Inspections on file
- 59
- Latest survey
- March 24, 2026
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Estates Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including dementia, Parkinson’s disease, cirrhosis, and psychiatric diagnoses, experienced a documented 15.9% weight loss over one month, dropping from approximately 145 lbs to 122 lbs. Despite facility policy requiring monthly weights, re-weighs within 24 hours for significant changes, and immediate notification of the MD, RD, and family for >5% weight loss, the March weight was not promptly entered into the EHR, no re-weigh was documented, and no new dietary orders or nutrition-focused care plan interventions were initiated. The DON acknowledged missing the entry of the weight, which prevented automated alerts and review, while the MD and RD both stated they expected to be notified of such a change. Staff interviews indicated the resident had a good appetite and ate most meals, but the facility failed to recognize and act on the significant documented weight loss in accordance with its policies.
A resident with multiple chronic conditions, including dementia, Parkinson’s disease, cirrhosis, and psychiatric diagnoses, experienced a significant unaddressed weight loss over several months. EHR vitals showed a drop from the mid-140 lb range to just over 120 lbs, but the annual MDS documented no or unknown weight loss and the care plan contained no nutrition or weight-loss focus. The MDS nurse relied on incomplete weight data because current weights were not promptly entered into the system, and no alert for weight loss was generated. The DON reported that weights were first recorded on paper by the Activity Director and later entered into the electronic system, but the resident’s most recent weight was not entered before weekly review or the annual MDS, so the weight loss did not trigger review or care planning, resulting in an inaccurate assessment.
A resident with moderate cognitive impairment and multiple complex diagnoses experienced a significant, documented weight loss over several weeks, but the facility failed to develop a comprehensive care plan addressing nutrition and weight loss. The resident’s care plan focused on dental issues and contained no nutrition or weight-loss interventions, and the Annual MDS documented no or unknown weight loss. Weights were taken and recorded on paper by the Activity Director, but the DON did not enter the most recent weight into the electronic system by the facility’s required timeframe, preventing automated triggers for weight loss and review during weekly meetings. The MDS nurse, relying on incomplete electronic weight data and system alerts, did not identify the weight loss, resulting in the absence of appropriate care plan goals and interventions for the resident’s significant weight change.
A resident with diabetes, bilateral above-knee amputations, heart failure, and a history of constipation went several days without a documented BM despite a PRN order for bisacodyl suppositories to be used if no BM occurred within 48 hours. The MAR showed the suppository was given only twice during this period, and the resident later reported abdominal discomfort and believed his last BM had been the previous week. An RN, unaware of the prolonged absence of a BM, contacted the physician only after the resident requested an enema, then administered a suppository per the physician’s direction, resulting in a large BM. CNAs reported they documented BMs on flowsheets but did not routinely review bowel patterns, assuming the nurse would be notified electronically, while the DON stated the system should alert nurses after two days without a BM and acknowledged there was no specific constipation policy.
A resident with multiple chronic conditions, including dementia, Parkinson’s disease, cirrhosis, and psychiatric disorders, experienced a documented 15.9% weight loss over one month, but staff did not recognize or act on this change. Monthly weights were obtained and written on paper by the Activity Director, but the DON did not timely enter the most recent weight into the EHR, preventing automated alerts and review. The resident’s MDS inaccurately reflected no weight loss, the care plan lacked any nutrition or weight-loss focus, no re-weigh was documented, and no MD or RD notification or dietary interventions were initiated despite facility policy defining significant weight loss and outlining required actions. Interviews with the MD, RD, CNA, DON, Compliance Nurse, and Activity Director confirmed that the expected processes for monitoring and responding to significant weight changes were not followed for this resident.
Staff failed to keep a clean linen cart covered and left a sealed red biohazard bag unattended in a hallway after wound care. Multiple staff members acknowledged responsibility for maintaining sanitary conditions, but did not follow infection control protocols as outlined in facility policy. These lapses resulted in exposed linen and improper handling of potentially infectious materials.
Two residents with documented mood and behavioral issues, including anxiety, refusal of care, and mental health diagnoses, were not accurately coded for these conditions in their MDS assessments. Despite care plans, physician notes, and staff interviews confirming ongoing behavioral and mood disturbances, the MDS assessments failed to reflect these issues, resulting in inaccurate documentation of their status.
Two residents requiring respiratory support did not have their nasal cannula tubing and CPAP mask properly stored in clean, dated plastic bags when not in use, as required by facility policy and professional standards. Staff interviews confirmed the expectation for proper storage, but the equipment was found unbagged or inappropriately stored, and staff failed to notice or address the issue.
Staff failed to follow proper infection control procedures for three residents, including improper use of PPE, inadequate hand hygiene, and cross-contamination during wound care. Housekeeping and nursing staff demonstrated lack of awareness and training regarding enhanced barrier precautions and cleaning protocols for fungal infections.
A resident with chronic kidney disease and multiple comorbidities missed three consecutive dialysis sessions, and facility staff failed to document all missed treatments, review critical lab results promptly, or ensure appropriate monitoring and intervention. Despite the resident's ongoing refusals, there was inadequate follow-up and communication with the dialysis center, and the care plan was not updated until after surveyor involvement.
Multiple residents experienced abuse due to inadequate supervision and staff misconduct. Two residents with dementia engaged in a prolonged physical altercation in a memory care unit while the assigned nurse was in the office and failed to intervene promptly, resulting in injuries. In a separate event, a CNA verbally abused a resident during an exchange, causing emotional distress. These incidents demonstrate lapses in supervision and staff conduct, leading to resident harm.
Two residents with dementia and a history of behavioral risks were left unsupervised in a common area, leading to a physical altercation in which one resident was punched multiple times and sustained facial injuries. The assigned RN was in the office with the door closed and did not have visual access to the residents, resulting in a delayed response and failure to prevent or promptly intervene in the incident.
Two residents with PASRR positive status did not have their specialized services documentation submitted within the required timeframe after interdisciplinary team meetings. Both residents had complex medical and mental health needs, and while services were reportedly provided, required forms were delayed due to technical issues with the documentation portal and internal communication lapses. The Director of Rehabilitation was responsible for timely submission but encountered system glitches and backlogs, resulting in noncompliance with facility policy.
A resident with chronic medical conditions and no cognitive impairment reported to an LVN that a CNA used profanity towards him, causing distress. The LVN reassigned the CNA but did not immediately notify the Administrator as required by policy. The incident was only reported to the Administrator and DON the following day after the resident informed the Social Worker, resulting in a delay in investigation and intervention.
Three residents experienced abuse, including a case where a CNA antagonized and physically contacted a resident with severe cognitive impairment, and another incident where two residents engaged in a verbal and physical altercation after one verbally abused the other. Both incidents involved failures to prevent emotional, mental, and physical abuse, with affected residents at risk of psychological harm.
A resident with a high fall risk and double amputation sustained a head injury after his wheelchair's anti-tippers were removed during dialysis at his request, and staff failed to ensure their reapplication before transport. The resident attempted to board the facility van independently, against the van driver's instructions, and fell backwards when his wheelchair tipped on the lift, resulting in abrasions to his head and elbow.
Two residents did not receive pharmaceutical services that ensured accurate dispensing and administration of PRN pain medications. One resident with a recent opioid overdose was given hydrocodone/acetaminophen against hospital discharge instructions, and documentation was incomplete or inconsistent. For another resident, there were discrepancies between the narcotic log and the MAR, with staff failing to document PRN medication administration as required by facility policy. Staff interviews confirmed these documentation lapses and failure to follow physician orders.
Two residents in a facility experienced significant safety failures. One resident with cognitive impairment eloped from a secure unit by prying open a window and was found 0.9 miles away, carrying potentially dangerous items. Another resident, who was paraplegic, was not properly secured in a transport van, resulting in a fall and head injury. Both incidents were due to inadequate supervision and safety measures, highlighting deficiencies in the facility's care protocols.
A resident with pressure ulcers and a malfunctioning wound vacuum reported feeling unwell, but RN C delayed care for nearly 10 hours, failing to assess or address the resident's condition in a timely manner. The facility did not follow policies for notifying physicians or ensuring timely wound care, leading to a deficiency in care.
A resident with a history of pressure ulcers did not receive timely wound care after reporting a leaking wound vac to RN C. The resident experienced discomfort and drainage due to a 10-hour delay in care, as RN C did not have enough supplies and failed to prioritize the resident's needs. Interviews revealed ongoing issues with staff training and communication regarding wound care procedures.
The facility failed to ensure proper dialysis communication for two residents with end-stage renal disease, missing multiple communication forms from the dialysis center. This deficiency involved not receiving or documenting necessary information, despite the residents attending regular dialysis sessions. Staff interviews revealed a lack of adherence to the facility's dialysis policy, highlighting the importance of these forms for continuity of care.
The facility failed to provide adequate pharmaceutical services, with discrepancies in narcotic logs and expired medications on a medication cart. A nurse was observed mishandling medications, including not documenting narcotic administration and failing to destroy unused medication. Interviews revealed that facility policies were not followed, contributing to these deficiencies.
A resident with multiple medical conditions, including pressure ulcers, reported feeling unwell and having issues with his wound vacuum to RN C. Despite the resident's pale appearance and complaints, RN C delayed addressing his needs and failed to notify the physician or DON. The resident's condition was not reassessed, and the physician was not informed, leading to a deficiency in care.
A resident with severe cognitive impairment and malnutrition risk did not receive a speech therapy evaluation as ordered by a physician. The facility's communication breakdown led to the speech therapist not being informed of the order, and the DON was unaware of the dietician's recommendation. The lack of a facility policy on following physician orders contributed to this oversight.
A resident fell in a van due to improper wheelchair strapping, resulting in a head injury and hospital visit. The facility failed to report the incident to the State Survey Agency, as the Administrator believed the transport company would handle it. The resident, with a history of paraplegia and other conditions, was at risk for falls, and the incident was not reported within the required timeframe.
A resident with paraplegia fell in a transport van due to improper wheelchair securing, resulting in a head injury. The facility failed to investigate or report the incident to the state agency, as the Administrator believed the transport company was responsible. This inaction placed the resident at risk of further harm.
The facility failed to ensure proper labeling and secure storage of insulin vials on a medication cart. An observation revealed an opened Humalog vial without an open date and a Levemir vial with an incorrect date. Interviews with RN C, the ADON, and the DON highlighted a lack of adherence to the facility's policy on dating insulin vials, with no recent training documentation provided.
A resident with multiple health conditions and moderate cognitive impairment fell and fractured her femur during a bed bath when a CNA failed to obtain the required assistance from another staff member. Despite the resident's care plan indicating the need for two staff members due to her bariatric status, the CNA proceeded alone, leading to the accident.
A resident with multiple health issues, including chronic kidney disease and urine retention, did not have a comprehensive care plan implemented to monitor signs of dehydration. Despite the care plan identifying potential fluid deficit, there was no evidence of monitoring in the resident's records. Observations showed no urine output in the catheter bag, and staff interviews revealed inconsistencies in monitoring and documentation. The facility's policy required a comprehensive care plan, but it was not effectively implemented, placing the resident at risk.
A resident with an indwelling urinary catheter was not properly monitored for urine output and signs of dehydration, despite having a care plan indicating the need for such monitoring. Observations showed no urine output in the catheter bag, and staff interviews revealed inconsistencies in monitoring and documentation. The facility's policy required comprehensive care plans, but the lack of adherence led to a deficiency in care.
The facility failed to secure a medication cart on Hall 200, leaving it unlocked and unattended on two occasions. LVNs involved acknowledged the risk and the requirement to lock the cart, as per the facility's policy. The DON and Administrator confirmed staff responsibility for securing the cart.
A resident's call light was not within reach, as it was placed on the other side of a privacy curtain over a vacant bed's headboard. The resident, who required assistance for daily activities and had a recent fall, was unable to locate the call light. Staff, including the DON and CNAs, were unaware of the issue, although they acknowledged the importance of accessible call lights for resident safety. The facility's policy on resident rights was not upheld in this instance.
A resident with a history of falls and severe cognitive impairment fell from her bed, sustaining a bruise on her forehead, due to the facility's failure to place fall mats on both sides of her bed. The care plan did not initially include fall mats as an intervention, and staff acknowledged the oversight. The facility's Fall Risk Assessment policy was not adequately followed, leading to the resident's fall and injury.
A resident with severe cognitive impairment suffered a burn blister on her wrist after spilling hot coffee on herself in the dining room. The incident occurred because the resident, who wore gloves to prevent skin scratching, lost grip of the cup. Despite the facility's care plan to prevent burns, the interventions were not effectively implemented, leading to the injury.
The facility failed to ensure disposable razors were kept out of reach in a shower room, posing a risk of injury to residents. Razors were found on top of a sharps container, accessible to residents, contrary to the facility's policy requiring proper storage. Staff interviews confirmed the risk of harm if razors were not disposed of correctly.
The facility did not have a full-time Director of Nursing (DON) for 53 out of 65 days, as the responsibilities were divided among the ADON, MDS Coordinator, and Regional Compliance Nurse. The Administrator acknowledged the absence of a dedicated DON and the lack of a policy for DON coverage.
Failure to Notify Physician and Address Significant Resident Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician when there was a significant change in the resident’s nutritional status, specifically a substantial weight loss. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS dated mid-March reflected a weight of 145 pounds and no or unknown weight loss, and his care plan included a focus on dental health problems but did not include a focus or interventions related to nutrition or weight loss. Laboratory results from early March showed a low glucose level of 68 and a slightly low albumin level of 3.3. Record review of the resident’s weights showed that he weighed 148.2 lbs in early January, 145.5 lbs in early February, and 122.4 lbs in early March, representing a 15.9% loss and a 23.1 lb decrease between early February and early March. There were no documented re-weighs after the March weight, and there were no physician orders addressing weight loss despite this significant change. The facility’s weekly resident review on March 12 did not list any triggers for weight loss in 30 days, and the resident was not reviewed. The DON later stated that she entered all weights into the electronic health record but had missed entering this resident’s March 9 weight, which prevented the system from triggering an alert for weight loss and from identifying the change during the weekly review and MDS update. Interviews with staff showed that CNAs and the Activity Director observed the resident to have a good appetite and to usually eat most or all of his food, and the resident himself reported that he felt well, did not feel he was losing weight, and felt he received enough food, including preferred cultural foods. The DON stated that a weight loss of over 5% should have been immediately reported to the MD, RD, and family, and acknowledged that missing significant weight loss could place residents at risk of untreated serious health conditions. The MD stated his expectation was to be notified of any weight change over 5% gain or loss and that he had not been informed of this resident’s significant weight loss. The RD stated that if a resident had more than 5% weight loss in one month, she would expect immediate notification and interventions such as re-weighs, fortified diet, supplements, and weekly weights. The facility’s written policies on notifying the physician of change in status and on resident weights required timely weighing, review of weights for significant changes, re-weighs within 24 hours, and notification of the physician and family for significant weight loss, but these procedures were not followed for this resident’s documented 15.9% weight loss. The DON further explained that the Activity Director was responsible for obtaining monthly weights and documenting them on paper, while the DON was responsible for entering them into the electronic system and reviewing them for significant changes. The facility did not keep a running log of weights on the paper document, and the Activity Director was not responsible for monitoring the numbers for significant changes. The DON stated that she was behind on documentation due to training and did not enter the resident’s March 9 weight until after the 15th of the month, which caused the weight loss to be missed during both the weekly resident review and the MDS assessment process. The Compliance Nurse stated that the expectation for significant weight loss was to re-weigh and notify the MD, RD, and family, and to update the care plan with interventions such as weekly weights and a nutrition risk program, but could not state whether the resident’s weight was accurate or why there was no documented re-weigh. Overall, the facility did not follow its own policies and did not immediately notify the physician or implement care plan interventions in response to the resident’s significant weight loss.
Inaccurate MDS Assessment Due to Missed Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for a resident who experienced significant weight loss. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS, dated 03/15/26, documented him as 66 inches tall and 145 pounds with no or unknown weight loss, despite electronic health record (EHR) vitals showing a substantial decrease in weight over the preceding months. Record review showed the resident’s weights as 148.2 lbs on 01/09/26, 145.5 lbs on 02/10/26, and 122.4 lbs on 03/09/26, with no documented re-weighs. A weights and vitals summary dated 03/24/26 reflected that the 03/09/26 weight of 122.4 lbs represented a 15.9% loss (23.1 lbs) from the 02/10/26 weight. The resident’s care plan, dated 05/14/25, contained a focus on dental health problems with related interventions but did not include a focus or interventions regarding nutrition or weight loss. A weekly resident review document from 03/12/26 showed there were no triggers for weight loss in 30 days and the resident was not reviewed. In interviews, the MDS nurse stated she had been in the role for about 11 months and that significant weight loss should trigger an alert in the system for MDS updating. She reported that when she completed the resident’s annual MDS on 03/15/26, there was no alert for weight loss and that current weights were not always entered into the system immediately, so she used the data available at the time. The DON stated that weekly meetings were held to review residents who triggered alerts for ADL declines, including weight loss, but the resident did not trigger because the 03/09/26 weight had not been entered. The DON acknowledged she was behind on documentation due to training and did not enter the 03/09/26 weight until after the 15th, causing the resident’s significant weight loss to be missed during both the weekly review and the MDS update, and resulting in an inaccurate MDS assessment and missed opportunity to identify the weight loss. The facility’s comprehensive care planning policy required use of the MDS to identify needs and revise care plans after each MDS assessment, but this process did not occur for the resident’s weight loss because the data were not timely entered and did not trigger further assessment or care planning.
Failure to Care Plan for Significant Weight Loss Due to Delayed Weight Entry and Inaccurate MDS Data
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s significant weight loss. The resident was an older male with moderate cognitive impairment (BIMS score of 9) and multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS assessment dated 03/15/26 documented no or unknown weight loss, and his care plan dated 05/14/25 included a problem focus on dental health but did not include any focus, goals, or interventions related to nutrition or weight loss. Record review showed that the resident’s weight declined from 148.2 lbs on 01/09/26 to 145.5 lbs on 02/10/26, and then to 122.4 lbs on 03/09/26, representing a documented 15.9% loss and 23.1 lbs lost between 02/10/26 and 03/09/26. There were no documented re-weighs after the 03/09/26 weight. A weights and vitals summary dated 03/24/26 reflected the 03/09/26 weight of 122.4 lbs with a noted percentage change, but this information was not incorporated into the MDS or care plan at the time of the Annual MDS assessment. The facility’s weekly resident review on 03/12/26 contained no triggers for weight loss in 30 days, and the resident was not reviewed for weight loss. Interviews revealed that the MDS nurse relied on system alerts and available weight data when completing MDS assessments and stated that significant weight loss should trigger an alert and lead to updated assessments and care plan interventions. She reported that no alert appeared for this resident’s weight loss because current weights were not always entered into the system in a timely manner, and she used the data that were available, which did not reflect the significant loss. The DON stated that she was responsible for entering weights from paper records into the electronic system and acknowledged that the resident’s 03/09/26 weight was not entered by the time of the weekly review or the subsequent QAPI meeting, due to being behind on documentation. The DON also stated that the Activity Director took and recorded weights on paper without a running log, and that the facility’s policy required weights and documentation to be completed by the 10th of each month. As a result of these delays and omissions, the resident’s significant weight loss was not identified in the MDS, did not trigger review, and was not addressed in a comprehensive care plan as required by the facility’s Comprehensive Care Planning policy.
Failure to Treat Resident Constipation per Physician Orders and Bowel Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care for constipation as ordered by the physician and in accordance with the resident’s comprehensive assessment and care needs. A cognitively intact male resident with diabetes, bilateral above-knee amputations, heart failure, and constipation had an admission MDS showing he required partial assistance with toileting and a care plan noting self-care deficit and fall risk. The bowel continence flow sheet showed no bowel movement documented for this resident from 03/17/26 through 03/24/26, despite an existing PRN order dated 03/14/26 for a Dulcolax (bisacodyl) 10 mg rectal suppository every 12 hours as needed for constipation if no bowel movement occurred in 48 hours. The MAR reflected the suppository was administered only on 03/14/26 and again on 03/24/26, indicating the order was not used to address the multi-day absence of bowel movements. On 03/24/26 in the morning, the resident reported needing something for constipation, described abdominal discomfort, and believed his last bowel movement had been the previous week. He requested an enema from an RN, who stated he would need to contact the physician because there was only an order for a suppository. The RN contacted the physician, who instructed him to administer the suppository first and call back if there were no results; the RN then administered the suppository around 11:15 AM, after which the resident had a large bowel movement. The RN stated he was unaware the resident had not had a bowel movement since the prior week and indicated CNAs were responsible for documenting bowel movements and notifying the nurse if there was no bowel movement for more than two days. A CNA reported the resident had not complained to her about not having a bowel movement and that CNAs typically did not review bowel patterns in the Kardex, believing the nurse was notified by the computer. The DON stated residents should not go more than three days without a bowel movement and that the system was designed to alert nurses if no bowel movement was documented in two days, but she did not know whether the alert was missed or failed to activate, and also stated there was no specific facility policy addressing constipation.
Failure to Identify and Address Significant Weight Loss and Nutritional Status
Penalty
Summary
The deficiency involves the facility’s failure to recognize, evaluate, and address a resident’s significant weight loss and nutritional status. The resident was an older male with multiple active diagnoses, including non-Alzheimer’s dementia, Parkinson’s disease, depression, schizophrenia, history of alcohol abuse, cirrhosis, metabolic encephalopathy, and a benign neoplasm of the sigmoid colon. His Annual MDS, dated 03/15/26, documented a weight of 145 pounds and indicated no or unknown weight loss, and his care plan contained a focus on dental health problems but no focus or interventions related to nutrition or weight loss. The resident’s diet order was for a regular diet with mechanical soft texture and regular consistency, and there were no physician orders addressing weight loss. Weight records in the EHR showed that the resident weighed 148.2 lbs on 01/09/26, 145.5 lbs on 02/10/26, and 122.4 lbs on 03/09/26, reflecting a documented 15.9% loss between 02/10/26 and 03/09/26. There were no documented re-weighs within 24 hours as required by facility policy, and the facility’s weekly resident review on 03/12/26 showed no triggers for weight loss in 30 days, so the resident was not reviewed. Lab work from 03/02/26 showed a low glucose of 68 and a slightly low albumin of 3.3, but there was no documentation that these findings were linked to an evaluation of his nutritional status or weight loss. The DON later acknowledged that she had not entered the 03/09/26 weight into the electronic record in a timely manner, which resulted in the resident not triggering for review and the MDS assessment remaining inaccurate regarding weight loss. Staff interviews and observations further demonstrated that the significant weight loss was not recognized or acted upon. The CNA reported that the resident usually ate all his food, preferred outside food, and appeared to have lost a little weight, which she stated nurses were aware of, but there was no documentation of follow-up. The DON stated that the resident did not appear physically smaller, that no nurses had reported concerns, and that she must have missed the resident’s weight loss when entering weights into the system. The Activity Director, who was responsible for obtaining monthly weights and had weighed the resident on 02/10/26 and 03/09/26 using the mechanical lift scale, stated she wrote the weights on paper and gave them to the DON, was not responsible for entering them into the EHR, and had not noticed any physical changes in the resident’s weight. The facility’s written policy required monthly weights by the 10th, review of all weights by the DON or designee, re-weighs within 24 hours when indicated, and specific actions for significant weight changes, but these procedures were not carried out for this resident, resulting in the failure to maintain acceptable parameters of nutritional status and to address a documented significant weight loss. Additional interviews with the MD, RD, Compliance Nurse, and other staff confirmed that the expected process for significant weight loss—re-weighing, notifying the MD, RD, and family, updating the care plan, and implementing interventions such as fortified diets, supplements, and weekly weights—was not initiated because the weight loss was not identified through the facility’s monitoring systems. The MD stated he expected notification for weight changes over 5% and consultation with the RD, but he was not informed of the resident’s significant weight loss. The RD stated she would expect immediate notification for more than 5% weight loss in one month and would advise re-weighs and nutritional interventions, but she reported that the resident’s weight had been considered stable and that she had no recollection of weight concerns. The Compliance Nurse described the facility’s expectations for managing significant weight loss, including re-weighs, notifications, care plan updates, and staff in-servicing, but could not confirm the accuracy of the resident’s weight or explain the lack of a documented re-weigh. Overall, the facility did not follow its own weight monitoring policy or implement appropriate assessment and care planning in response to the resident’s documented 15.9% weight loss.
Failure to Maintain Infection Control: Uncovered Linen Cart and Improper Biohazard Disposal
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by two specific incidents involving staff and environmental management. In one instance, a clean linen cart located in the 100 hall was observed with its cover left open, exposing the linen to potential environmental contamination. Multiple staff members, including an LVN, a CNA, and a medication aide, were present and acknowledged that the cart should have been covered when not in use to prevent contamination and unauthorized access. Staff interviews confirmed that it was the responsibility of all staff to ensure linen carts remained covered and sanitary. In a separate incident, a sealed red biohazard bag containing potentially infectious materials was found left on the floor in the hallway outside a resident's room in the 300 hall. Staff interviews revealed that the bag had been dropped by an LVN after wound care and was not immediately picked up or reported by another CNA who noticed it. The bag was eventually disposed of properly, but only after being left unattended in a public area, contrary to facility policy and infection control protocols. Both the LVN and CNA acknowledged the importance of immediate and proper disposal of biohazard materials to maintain a sanitary environment. Record review of the facility's Infection Control Policy and Procedure Manual confirmed that clean linen must be stored in a secured, covered cart and that biohazard materials must be properly labeled and disposed of immediately. The manual also specifies that all staff are responsible for maintaining sanitary conditions and preventing contamination. Interviews with the Administrator and DON further confirmed that these were the expected standards and that the observed lapses constituted a failure to follow established infection control procedures.
Failure to Accurately Code Mood and Behavior in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents regarding their mood and behavioral conditions. For one male resident with chronic respiratory failure, anxiety, and a history of refusing care and medications, the quarterly MDS assessment did not document any mood or behavioral issues, despite care plans and progress notes indicating frequent anxiety, refusal of care, false accusations, and attention-seeking behaviors. The resident's care plan specifically addressed behavioral problems and interventions, and physician notes documented ongoing behavioral concerns, yet these were not reflected in the MDS. A female resident with diagnoses including unspecified dementia, mood disorder, schizoaffective disorder, and major depressive disorder also had an MDS assessment that failed to document any mood or behavioral symptoms. Her care plan and physician orders indicated significant mental health issues, including risk for self-harm, aggression, and labile mood, with interventions in place to address these concerns. Observations and interviews with staff and family confirmed ongoing behavioral and mood disturbances, but these were not captured in the MDS assessment. Interviews with facility staff, including the MDS Coordinator, ADON, and DON, confirmed that the MDS assessments for both residents did not accurately reflect their mood and behavioral status. Staff acknowledged that these omissions could lead to inaccurate care planning and that the MDS Coordinator was responsible for ensuring assessment accuracy. The deficiency was identified through record reviews, staff interviews, and direct observation, revealing a failure to document and code mood and behavioral issues in the MDS for residents with clear histories and ongoing symptoms.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required respiratory support, as evidenced by improper storage of respiratory equipment. For one resident with diagnoses including heart failure, asthma, COPD, and respiratory failure, the nasal cannula and tubing were observed stored in a blue emesis bag attached to the concentrator, rather than in a clean, dated plastic bag as required to prevent environmental exposure and contamination. The resident reported using oxygen at night and was unsure when the tubing was last changed, indicating a lack of consistent adherence to proper storage and maintenance protocols. Another resident, admitted for short-term care with acute respiratory failure, shortness of breath, and obstructive sleep disorder, was observed with a CPAP mask left unbagged on the nightstand in his room. The resident stated he cleaned his own CPAP mask and tubing, but the tubing had not been bagged since his admission to the facility. Both residents were cognitively intact and had care plans and physician orders specifying the use of oxygen therapy or CPAP/BiPAP, with instructions for staff to monitor and store equipment appropriately. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that the expectation was for all respiratory equipment such as nasal cannulas and CPAP/BiPAP masks to be stored in clean, dated plastic bags when not in use. Staff acknowledged responsibility for ensuring proper storage and monitoring of respiratory equipment, but failed to notice or correct the improper storage for these residents. The facility's oxygen administration policy also required changing or cleaning equipment when contaminated, but this was not followed in these instances.
Failure to Maintain Effective Infection Control Practices
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices for three residents. For one resident with a history of metabolic encephalopathy, heart failure, candidiasis, chronic kidney disease, and other significant comorbidities, enhanced barrier precautions for Candida auris were not properly implemented. There was no signage on the resident's door indicating enhanced barrier precautions, and staff were observed improperly donning and doffing personal protective equipment (PPE), including failing to sanitize hands before donning gloves, dropping clean gloves on the floor and returning them to a pocket, and not properly cleaning hands after removing PPE. Additionally, a CNA was observed removing a gown incorrectly and not performing hand hygiene after glove removal. For another resident with cerebral palsy, contractures, and a gastrostomy, staff were observed gathering wound care supplies with dirty gloves and placing clean bandages on a contaminated surface before use. During wound care, the nurse did not use proper hand sanitizer after each glove change, and the assisting CNA improperly removed her gown and failed to dispose of it correctly. A third resident, who had acute kidney failure and unstageable pressure ulcers, was subjected to cross-contamination when dirty linen was placed on the bed and clean linen was subsequently placed on top of it. The assisting CNA again improperly removed her gown and handled clean linen after contact with contaminated items. Interviews with staff revealed a lack of awareness and training regarding infection control protocols, particularly for residents with fungal infections or those requiring enhanced precautions. The Housekeeping Manager was unaware of CDC cleaning guidelines for fungal infections and did not receive communication from nursing staff about residents on isolation. The Regional Compliance Nurse and other staff members demonstrated gaps in knowledge about infection control procedures and communication processes. Review of facility policies showed that while general infection control measures were outlined, the wound treatment management policy did not address infection control protocols during wound care.
Failure to Monitor and Intervene After Multiple Missed Dialysis Treatments
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the resident, who had multiple diagnoses including chronic kidney disease and was dependent on dialysis, refused three consecutive dialysis treatments. Despite this, there was no documentation of the missed treatments for two of the dates, nor were there documented attempts to send the resident to the hospital for evaluation after missing three treatments. The care plan was only updated to address dialysis non-compliance after the surveyor entered the facility. The resident's medical records indicated significant health concerns, including metabolic encephalopathy, heart failure, diabetes, morbid obesity, COPD, and major depressive disorder. The resident required extensive assistance with most activities of daily living and had moderate cognitive impairment. Laboratory results showed several abnormal values, including elevated glucose, BUN, and creatinine, as well as low albumin and total protein, which were not promptly reviewed or acted upon by the clinical team. The resident reported feeling slightly bloated but otherwise fine, and interviews revealed that the facility staff, including the PA and MD, were aware of the refusals but did not follow established protocols for monitoring or escalation. Interviews with facility staff and the dialysis center social worker highlighted a lack of communication and follow-up after the resident missed multiple dialysis sessions. The facility's policy required documentation and notification when a resident refused dialysis but did not specify follow-up procedures for care after refusal. The PA admitted to not reviewing critical lab results in a timely manner, and the facility did not ensure appropriate monitoring or intervention after repeated missed treatments, placing the resident at risk for delayed medical evaluation and treatment.
Failure to Prevent Resident Abuse and Inadequate Supervision
Penalty
Summary
The facility failed to protect multiple residents from abuse, including both resident-to-resident physical altercations and staff-to-resident verbal abuse. On the memory care unit, two residents with moderate cognitive impairment and histories of behavioral issues were left unsupervised in a common area. The nurse assigned to the unit, RN K, was in the office with the door closed and did not have visual access to the residents. As a result, a physical altercation occurred in which one resident punched another approximately eight times in the face and head, causing visible injuries including facial swelling and an abrasion. Surveillance video confirmed that the altercation lasted close to two minutes before RN K exited the office and intervened. Staff interviews and documentation revealed that the nurse was slow to respond and did not call for help during the incident. In a separate incident, a resident who was cognitively intact reported being verbally abused by a CNA. The resident stated that after a brief exchange, the CNA used profane language towards him, which made him feel upset and uncomfortable. The incident was corroborated by the resident's roommate and the CNA herself, who admitted to using inappropriate language in response to the resident's provocation. The nurse on duty and the social worker both confirmed that the resident was visibly upset after the incident and that the language used by the CNA constituted verbal abuse. Additionally, another incident involved a resident being physically assaulted by another resident, resulting in the victim being punched in the face. The report details that these failures to provide adequate supervision and to ensure staff refrained from abusive language or behavior led to residents experiencing physical and psychological harm. The facility's lack of timely intervention and failure to maintain a safe environment contributed directly to the deficiencies identified by surveyors.
Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Altercation
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision to prevent accidents, specifically for two residents on the memory care unit. Both residents had moderate cognitive impairment and dementia diagnoses, with care plans identifying risks for physical aggression and the need for close monitoring. Despite these documented risks, the residents were left unsupervised in a common area, which led to a physical altercation. On the day of the incident, both residents were in the television room when one resident pushed the other, leading to a physical fight in which one resident was punched multiple times in the face and head. The nurse assigned to the unit, RN K, was in the nurse's office with the door closed and did not have visual access to the residents. Surveillance footage showed that the altercation lasted for nearly two minutes before RN K exited the office and intervened. During this time, the residents continued to struggle on the floor, resulting in visible injuries, including facial swelling and abrasions. Interviews and record reviews confirmed that the nurse was slow to respond and did not immediately call for assistance. The CNA on duty was occupied in another room and was unaware of the incident until after it occurred. The lack of adequate supervision and delayed intervention allowed the altercation to escalate, resulting in harm to one of the residents. Staff and leadership interviews further corroborated that the nurse's failure to maintain visual supervision and timely response contributed directly to the incident.
Failure to Timely Submit PASRR Specialized Services Documentation
Penalty
Summary
The facility failed to incorporate recommendations from the PASRR Level II determination and evaluation reports into the assessment, care planning, and transitions of care for two residents who were PASRR positive. For one resident with diagnoses including anxiety disorder, depression, schizophrenia, bipolar disorder, and unspecified intellectual disabilities, the facility did not submit the required Nursing Facility Specialized Services (NFSS) form within 20 business days following an interdisciplinary team (IDT) meeting. The resident's care plan identified the need for specialized services such as customized manual wheelchair, specialized therapy assessments, and habilitation services, all of which were accepted by the resident. However, documentation from the IDT meeting was not uploaded into the required portal in a timely manner, and the Director of Rehabilitation reported delays due to a system glitch and backlog in obtaining physician signatures. Another resident, diagnosed with cerebral palsy, scoliosis, and benign prostatic hyperplasia, also did not have the NFSS form submitted within the required timeframe after an IDT meeting where a customized wheelchair and therapy services were recommended. The Social Services Director was not fully aware of the resident's eligibility for specialized services and was only involved in making ancillary referrals. The Director of Rehabilitation acknowledged responsibility for submitting the NFSS forms and described technical issues with the portal that delayed submission. Despite these delays, the resident continued to receive therapy services, but the process for obtaining a customized wheelchair was delayed due to missed appointments with third-party vendors. Interviews with facility staff, including the Social Services Director, MDS Coordinator, and Administrator, confirmed that the Director of Rehabilitation was responsible for timely submission of required documentation. The facility's policy required NFSS forms to be submitted within 20 business days of the IDT meeting, but this was not consistently followed. The delays in documentation and submission of forms were attributed to technical issues with the portal and internal communication gaps, resulting in the failure to timely incorporate PASRR recommendations into resident care planning and service delivery.
Failure to Immediately Report Alleged Verbal Abuse to Administrator
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to immediately report an allegation of verbal abuse involving a resident and a certified nursing assistant (CNA) to the facility Administrator, as required by policy. The incident involved a male resident with a history of Type 2 Diabetes Mellitus, Chronic Pain Syndrome, and Cognitive Communication Deficit, who was dependent on staff for activities of daily living and had no cognitive impairment. The resident reported that the CNA used profanity towards him, which made him feel upset and uncomfortable. The resident immediately informed the LVN, who then reassigned the CNA but did not notify the Administrator at that time. Interviews revealed that the LVN initially claimed to have reported the incident to the Administrator and Director of Nursing (DON), but later admitted she might not have done so, believing the CNA had already reported it. The DON and Administrator both confirmed that they were not made aware of the incident until the following day, after the resident reported it to the Social Worker. The facility's policy requires all staff to make an immediate verbal report to the Abuse Preventionist or designee when any suspected abuse is identified, regardless of the time of day. The failure to report the allegation immediately delayed the facility's investigation and intervention. The Administrator's contact information was posted throughout the building, and staff were expected to notify her of any abuse allegations without delay. The DON and Administrator both stated that immediate reporting is necessary to ensure resident safety and prevent further harm.
Failure to Protect Residents from Abuse by Staff and Peers
Penalty
Summary
The facility failed to ensure that three residents were free from abuse, resulting in two separate incidents involving both staff-to-resident and resident-to-resident abuse. In the first incident, a male resident with severe cognitive impairment and a history of anxiety disorder and vascular dementia was subjected to emotional and mental abuse by a CNA. Video footage showed the CNA antagonizing the resident, including placing her hand on his knee for an extended period while verbally confronting him about his language and behavior. The resident, who was dependent on staff for activities of daily living and had a care plan addressing behavioral issues, was observed to be verbally aggressive, but the CNA escalated the situation by engaging in a prolonged argument and physical contact that was not necessary for care. The CNA admitted to correcting the resident and acknowledged that her actions were inappropriate. In the second incident, two male residents, one with moderate cognitive impairment and a history of bipolar disorder and dementia, and the other with diagnoses including anxiety disorder and schizoaffective disorder, were involved in a verbal and physical altercation. The altercation began when one resident verbally abused the other by repeatedly calling him derogatory names, despite being asked to stop. This provoked the second resident to physically strike the first resident in the face. The incident was witnessed by a speech and language therapist, who intervened to separate the residents. Both residents had no prior history of physical or verbal behaviors towards others as documented in their assessments, and both were assessed with no injuries following the incident. Both incidents were identified as past noncompliance, with the facility having already addressed the issues before the investigation began. The failures in these cases involved staff engaging in antagonistic and abusive behavior towards a resident, as well as inadequate prevention of resident-to-resident abuse, resulting in emotional, mental, and physical harm. The events placed the affected residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and psychological harm.
Failure to Ensure Wheelchair Safety Features Resulted in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident who used a manual wheelchair with anti-tippers had the anti-tippers removed during a dialysis treatment. The resident, who had a history of depression, obstructive uropathy, diabetes, and limited lower extremity mobility, was assessed as not cognitively impaired and had not experienced prior falls. Despite being care planned for fall risk and having anti-tippers as an intervention, the anti-tippers were removed at the dialysis center at the resident's request, and this change was not communicated to facility staff. Upon returning from dialysis, the resident attempted to board the facility van independently, positioning himself backwards on the van lift against the van driver's repeated instructions to wait for assistance and to face forward. Without the anti-tippers in place, the resident's wheelchair tipped backwards while the lift was flush with the ground, causing him to fall and sustain an abrasion to the back of his head and right elbow. The van driver did not notice the absence of the anti-tippers until after the incident, despite being responsible for ensuring the resident's wheelchair safety features were in place before transport. Multiple interviews confirmed that the anti-tippers were not on the wheelchair at the time of the fall, and that the resident had requested their removal while at the dialysis center. Facility staff, including the van driver and therapy staff, were aware that anti-tippers were a necessary intervention for this resident due to his high fall risk and double amputation. The lack of supervision and failure to ensure the resident's wheelchair was equipped with anti-tippers directly contributed to the fall and injury.
Failure to Accurately Dispense, Administer, and Document PRN Pain Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administration of medications for two residents reviewed for pharmacy services. For one resident, who had a history of opioid overdose and was discharged from the hospital with explicit orders not to receive opioid medications, a nurse administered hydrocodone/acetaminophen (Norco) despite these restrictions. Documentation was inconsistent, with the narcotic administration record indicating the medication was given, but the medication administration record and progress notes lacking corresponding entries. Interviews with nursing staff and administration confirmed that the hospital discharge orders were not properly followed, and the medication was not discontinued or clarified with the physician as required. For another resident, there were discrepancies between the narcotic administration record and the medication administration record regarding the administration of PRN pain medication. The narcotic log showed multiple instances of hydrocodone/acetaminophen being administered, but the medication administration record did not reflect these doses. Interviews with staff revealed that nurses were not consistently documenting PRN medication administration on both required records, which was acknowledged as a risk for medication errors, double dosing, or potential drug diversion. Facility policy required that all PRN medication orders specify the reason and frequency for use, and that administration be documented on the medication administration record, including symptoms prior to administration and results. The policy also required complete documentation in the nurse's notes or the designated area for PRN documentation. The failure to maintain accurate documentation and to verify current physician orders before administering medications resulted in medication errors and placed residents at risk for adverse outcomes.
Inadequate Supervision and Safety Measures Lead to Resident Elopement and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents. One resident, who had cognitive impairment and resided on a secure unit, managed to elope from the facility by prying open a window in his room. This resident was found 0.9 miles away from the facility, carrying a dinner knife, a fork, and a shaving razor, and became aggressive when approached by staff. The resident's care plan had identified him as at risk for wandering and elopement, but the facility did not have sufficient measures in place to prevent his escape, such as window alarms or more frequent monitoring. Another resident, who was paraplegic and required assistance with personal care, was not properly secured in a transport van, resulting in a fall that caused a head injury and a contusion on his right hand. The resident was being transported by an outside provider for a medical appointment when the incident occurred. The facility's staff did not ensure that the resident was safely secured in the van, and the transport provider did not properly strap the resident's wheelchair, leading to the fall when the van took off. Both incidents highlight a lack of adequate supervision and safety measures for residents at risk of accidents. The facility's failure to implement effective interventions and monitoring systems for residents with known risks contributed to these deficiencies, resulting in immediate jeopardy situations that required urgent corrective actions.
Removal Plan
- Administrator, DON, and/or designee will initiate an in-service regarding Elopement Response, Elopement Prevention, and Abuse/Neglect. All staff scheduled to work will be in-serviced prior to next shift worked.
- The Administrator will conduct elopement drills.
- The Administrator, DON, and ADON were in-serviced by the ADO and Regional Compliance Nurse on Elopement Prevention Policy to include implementing interventions for residents at risk for elopement, Elopement Response Policy, and Abuse/Neglect.
- Elopement Risks will be completed for all residents on the secured unit.
- AD Hoc QAPI Contributors will meet and review the elopement risk for all residents residing on the secured unit.
- All elopement events were reviewed by the facility QAPI committee members.
- All elopement risk care plan interventions will be reviewed and updated by the Regional Compliance Nurse, DON, and ADON. All interventions are in place and care planned.
- Administrator will monitor the locking mechanism on all the exit doors and windows in the secured unit.
- Administrator will review for 1:1 monitoring in the secured unit.
- Through daily rounds and duties, observe for visitors allowing residents to exit the facility unsupervised.
- Change the door code.
- The medical director was notified of the IJ situation.
- The Administrator will monitor the residents' windows in the secured unit for signs of tampering.
- The Administrator will also monitor the facility entrance and secured unit doors to ensure their locks are functioning properly as well as their alarms.
- Elopement drills will be continued so that all shifts are prepared for elopements.
Delayed Wound Care and Inadequate Response to Resident's Condition
Penalty
Summary
The facility failed to provide timely and appropriate wound care to a resident, leading to a deficiency in care. The resident, who had a history of paraplegia, neurogenic bladder, anxiety disorder, and pressure ulcers, reported feeling unwell and experiencing issues with his wound vacuum on the morning of February 9th. Despite the resident's report of not feeling well and the wound vacuum malfunctioning, RN C did not assess or address the resident's condition until later in the day, resulting in a significant delay in care. RN C acknowledged that the resident appeared pale and unwell, with leaking wounds, but chose to wait for the resident's decision about going to the hospital before proceeding with care. This decision led to a delay of nearly 10 hours before the wound care was addressed, during which time the resident's condition could have worsened. The resident and his family expressed concerns about the lack of timely wound care and the staff's inadequate training in handling wound vacuums. The Director of Nursing (DON) and the Administrator were not informed of the resident's change in condition or the issues with the wound vacuum until much later. The facility's policies on notifying physicians of changes in resident status and ensuring timely wound care were not followed, contributing to the neglect of the resident's needs. The failure to provide timely care and notify appropriate personnel placed the resident at risk of further complications.
Failure to Provide Timely Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure ulcers for a resident who was using a wound vacuum. The resident, who had a history of paraplegia and pressure ulcers, reported to RN C that he was not feeling well and needed his dressing changed due to a leaking wound vac. Despite this report, RN C did not follow up with the resident until approximately 10 hours later, at which point she discovered there were not enough supplies to complete the wound care. This delay resulted in the resident experiencing discomfort and wound drainage on his body, wheelchair, and bed linens. The resident's medical records indicated that he required regular wound care, including the use of a wound vac, which was to be changed on specific days and as needed. However, the records showed that care was not provided on the day the resident reported the issue, nor the following day. Interviews with the resident and his family member revealed ongoing issues with timely and consistent wound care, with staff reportedly lacking the proper training to assist with the wound vacuum. The resident expressed that his condition was not addressed until late in the day, despite his early morning request for care. Interviews with facility staff, including RN C, the DON, and the Administrator, highlighted a lack of communication and training regarding wound care procedures. RN C admitted to not prioritizing the resident's care and not having the necessary supplies, while the DON and Administrator acknowledged the need for staff training and timely response to resident needs. The facility's policies on skin integrity management and physician notification were not adhered to, contributing to the deficiency and placing the resident at risk of further complications.
Failure to Ensure Proper Dialysis Communication
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received appropriate services consistent with professional standards and their care plans. Two residents, both diagnosed with end-stage renal disease, were affected by this deficiency. The facility did not receive dialysis communication forms from the dialysis center for multiple days, which are crucial for maintaining continuity of care. These forms were missing for Resident #9 on ten occasions and for Resident #63 on twelve occasions. Resident #9, a female with intact cognition, and Resident #63, a male with severely impaired cognition, both had care plans that required monitoring for complications from dialysis. Despite this, the facility did not consistently receive or document the necessary communication from the dialysis center. Interviews with the residents confirmed that they attended dialysis sessions regularly and were aware of the forms they were supposed to bring back to the facility. Interviews with facility staff, including a registered nurse, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), revealed a lack of adherence to the facility's dialysis policy. The staff acknowledged the importance of the communication forms for ensuring continuity of care and the potential for missing critical information without them. Despite training on the dialysis communication process, the forms were not consistently collected or followed up on, leading to the deficiency.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by discrepancies in narcotic logs and expired medications on the 300 Hall nurses' medication cart. Specifically, the narcotic administration records for three residents did not match the actual pill counts in the blister packs. For one resident, the record showed 13 pills remaining, while the blister pack contained 12. Another resident's record indicated 7 pills remaining, but the blister pack had 6. A third resident's record showed 38 pills remaining, while the blister pack had 36. Additionally, a bottle of atropine with an expiration date of August 2024 was found on the cart, indicating a failure to remove expired medications. The report highlights that RN C was responsible for these discrepancies. RN C was observed removing a lorazepam tablet from its packaging and placing it in an unlabeled cup, which she then put in her pocket. She admitted to not administering the medication to the intended resident and failing to notify another nurse for its destruction. Furthermore, RN C did not sign off on the narcotic administration record log after administering medications to two residents, which could lead to potential medication errors. Interviews with the ADON and DON revealed that the facility had policies in place for medication administration and destruction, but these were not followed by RN C. The ADON stated that she expected staff to document medications immediately after administration and to destroy any medication that was removed but not administered. The DON emphasized the importance of proper documentation to prevent overdose and ensure effective resident management. Despite training sessions on medication administration, RN C did not attend these sessions, contributing to the observed deficiencies.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with the physician regarding a significant change in the health status of a resident, identified as Resident #67. This resident, a male with intact cognition and multiple medical conditions including paraplegia and pressure ulcers, reported feeling unwell to RN C. Despite the resident's pale appearance and complaints about his wound vacuum not functioning properly, RN C did not notify the physician or the Director of Nursing (DON) about the resident's condition throughout the shift. Resident #67's medical records indicated that he required regular wound care, including the use of a wound vacuum. On the day in question, the resident approached RN C early in the morning, expressing discomfort and the need for his wound dressing to be changed. However, RN C delayed addressing his needs until late in the afternoon, citing other priorities and a lack of supplies. During this time, the resident's condition was not reassessed, and the physician was not informed of the resident's deteriorating condition. Interviews with the resident, his family member, RN C, the DON, and the physician revealed a lack of timely communication and action regarding the resident's care. The DON and the physician were not informed of the resident's condition change, which could have led to a risk of infection or sepsis. The facility's policy required immediate notification of the physician in such cases, but this protocol was not followed, resulting in a deficiency in the standard of care provided to Resident #67.
Failure to Provide Speech Therapy Evaluation
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident who required a speech therapy evaluation as per physician orders. The resident, who had diagnoses including non-traumatic brain dysfunction, non-Alzheimer's dementia, malnutrition, and aphasia, did not receive the necessary speech therapy evaluation. The resident's care plan highlighted a potential risk for malnutrition, and the registered dietician had recommended a speech evaluation. However, the speech therapist was not informed of the order, and the director of rehabilitation did not pass the order to her, resulting in the resident not receiving the evaluation. Interviews revealed a breakdown in communication and process. The speech therapist stated she did not receive a referral, and the DON was unaware of the dietician's recommendation. The registered dietician had emailed the recommendation to several staff members, but the order was not acted upon. The administrator confirmed there was no facility policy regarding therapists following physician orders, which contributed to the oversight. This failure could place residents with therapy orders at risk of not achieving their highest practicable well-being.
Failure to Report Resident Fall Incident
Penalty
Summary
The facility failed to report an alleged violation involving neglect to the State Survey Agency in a timely manner. This incident involved a resident who fell backwards in his wheelchair, which lacked anti-tippers or brakes, hitting his head on the floor of a van during takeoff in the facility parking lot. The resident was sent to the hospital with a head injury and a contusion on his right hand. The resident reported that his wheelchair was not strapped down correctly, leading to the fall and subsequent blackout. The resident, a male with intact cognition, had a history of osteomyelitis, paraplegia, neurogenic bladder, anxiety disorder, and pressure ulcers. His care plan indicated he was at risk for falls due to paraplegia, with goals to prevent falls and serious injuries. On the day of the incident, the resident was being transported by an outside provider for a urology appointment. The Director of Nursing (DON) and the Social Worker were alerted to the incident by the van driver and found the resident in distress, with straps still attached to his wheelchair. The resident was assessed and sent to the hospital for further evaluation. The Administrator did not report the incident to Health and Human Services, believing it was unnecessary since the resident was in the care of an outside provider. The facility's policy required event reporting for incidents resulting in a change in resident status, but the Administrator assumed the transport company would handle the reporting. This oversight placed the resident at risk of further accidents and injury, as the incident was not reported within the required timeframe.
Failure to Investigate and Report Allegation of Neglect
Penalty
Summary
The facility failed to investigate and report an allegation of neglect involving a resident who fell backwards in his wheelchair while being transported by an outside provider. The incident occurred when the resident's wheelchair, which lacked anti-tippers or brakes, was not properly secured in the transport van. As a result, the resident hit his head on the floor of the van during takeoff, leading to a head injury and a contusion on his right hand. Despite the severity of the incident, the facility did not conduct a thorough investigation or report the event to the state agency as required. The resident involved in the incident was a male with a history of paraplegia, osteomyelitis, neurogenic bladder, anxiety disorder, and pressure ulcers. His cognitive function was intact, as indicated by a BIMS score of 14. On the day of the incident, the resident was being transported to a urology appointment by an outside provider because the facility's van was unavailable. During the transport, the resident reported that the van driver took off abruptly, causing him to fall and hit his head. The resident was subsequently sent to the hospital for evaluation and treatment. Interviews with facility staff, including the Director of Nursing (DON), Social Worker, and Administrator, revealed a lack of communication and responsibility in handling the incident. The DON and Social Worker were aware of the incident but did not ensure that an investigation was completed or that the state agency was notified. The Administrator, who was present at the scene, did not conduct an investigation or report the incident, believing that the responsibility lay with the transport company. This failure to act placed the resident and potentially other residents at risk of further harm.
Failure to Properly Label and Store Insulin Vials
Penalty
Summary
The facility failed to ensure proper labeling and secure storage of drugs and biologicals, specifically insulin vials, on one of the medication carts reviewed. During an observation, it was found that an insulin vial of Humalog was opened and partially used without being labeled with the open date. Additionally, a vial of Levemir was found with an incorrect date. This oversight was identified on the medication cart for Hall 200, which was under the responsibility of RN C. Interviews with RN C, the ADON, and the DON revealed a lack of adherence to the facility's policy requiring insulin vials to be dated upon opening. RN C admitted to not checking the cart for proper labeling and expired medications on the day of the observation. The ADON and DON both acknowledged the expectation for nurses to date insulin vials and the ADON's responsibility to monitor compliance weekly. However, there was no documentation provided to confirm recent training on these procedures, and the last cart check by the ADON was over a week prior to the observation.
Failure to Provide Adequate Supervision and Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required two staff members for assistance with all activities of daily living (ADLs). On the day of the incident, a Certified Nursing Assistant (CNA) provided a bed bath to the resident without the required assistance from another staff member. During the bed bath, the CNA asked the resident to turn to her side, which resulted in the resident falling to the floor and sustaining a fracture of her right femur. The resident involved was a female with a history of hypertension, seizure disorder, cellulitis, fibromyalgia, and muscle wasting. Her cognitive abilities were moderately impaired, and she was dependent on staff for showering and bathing, requiring the assistance of two or more helpers. Despite this, the CNA proceeded to bathe the resident alone, citing an inability to find another staff member to assist, even though the resident's care plan and Kardex system clearly indicated the need for two staff members. Interviews with various staff members, including other CNAs and nurses, confirmed that the resident was known to require two staff members for all care due to her bariatric status and safety concerns. The CNA involved admitted to knowing the requirement but chose to proceed alone, which directly led to the resident's fall and subsequent injury. The incident highlights a lapse in adherence to established care protocols and the failure to ensure the resident's safety during care.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. The resident, a male with multiple diagnoses including chronic kidney disease and urine retention, was readmitted to the facility after a hospital stay. Despite the care plan identifying a potential fluid deficit and the need to monitor signs of dehydration, there was no evidence of implementation in the resident's care tasks, TAR/NMAR, or eMAR for October 2024. Observations revealed that the resident's catheter urine collection bag had no urine output on multiple occasions, indicating a lack of monitoring for dehydration. Interviews with facility staff, including medical assistants, nurses, and the ADON, highlighted inconsistencies in monitoring and documenting the resident's urine output. Staff members were aware of the need to monitor urine output, but the care plan was not updated to reflect this requirement, and the necessary documentation was missing from the resident's records. The facility's policy required the development of a comprehensive care plan to meet the resident's needs, but this was not effectively implemented. Interviews with the Administrator and DON confirmed that the lack of monitoring could lead to dehydration or a UTI, and they acknowledged the importance of updating care plans during IDT meetings. However, the deficiency in implementing the care plan placed the resident at risk of not receiving necessary care and services.
Deficiency in Monitoring Urine Output and Dehydration
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in monitoring and documenting signs and symptoms of dehydration and urine output. The resident, a male with multiple diagnoses including intellectual disability, chronic kidney disease, and urine retention, was readmitted to the facility after a hospital stay. Despite the care plan indicating the need to monitor for signs of dehydration, there was no documentation or care tasks related to this monitoring in the resident's records for October 2024. Observations revealed that the resident's catheter urine collection bag had no urine output on multiple occasions, and interviews with staff indicated a lack of consistent monitoring and documentation of urine output. The resident himself reported that his catheter bag had not been emptied since early morning, and staff interviews revealed confusion about the monitoring process. The Treatment Nurse and other staff members acknowledged the need for monitoring urine output, but there was no evidence of this being done consistently or documented in the resident's electronic medical records. The facility's policy required comprehensive care plans to describe the services needed to maintain the resident's well-being, but the lack of monitoring and documentation for this resident's urine output and potential dehydration indicated a failure to adhere to this policy. Interviews with the Administrator and DON confirmed that the absence of monitoring could lead to serious health issues such as UTIs or dehydration, highlighting the deficiency in care provided to the resident.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with one of the six medication carts located on Hall 200. On two separate occasions, the medication cart was found unlocked and unattended. On the first occasion, an LVN left the cart unlocked at 12:30 PM, and it was later locked by the DON at 12:45 PM. On the second occasion, another LVN left the cart unlocked at 9:26 PM, shortly after arriving at the facility. Interviews with the involved LVNs revealed that they were aware of the requirement to lock the medication cart when not in use, acknowledging the risk of residents or staff accessing the medications. The facility's Medication Administration Procedures policy, revised in 2017, mandates that the medication cart must be completely locked after the medication administration process is completed. The Administrator and the DON confirmed that the nursing staff is responsible for ensuring the cart is locked before leaving it unattended.
Resident Call Light Inaccessibility
Penalty
Summary
The facility failed to ensure that a resident had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the call light for a resident was not within reach, as it was draped over the headboard of a vacant bed on the other side of a privacy curtain. This oversight was observed during a survey, and the resident, who was moderately cognitively intact and required maximum assistance for toileting and showers, was unable to locate the call light. The resident reported not calling for help and mentioned a recent fall while transferring herself to her wheelchair. Interviews with various staff members, including the Director of Nursing (DON), Licensed Vocational Nurse (LVN), Certified Nursing Assistants (CNAs), and the Regional Compliance Nurse, revealed that they were unaware of the call light's inaccessibility. They acknowledged that the call light should be accessible to all residents to ensure they can call for assistance. The facility's Administrator stated that managers conducted Champion Rounds to check on call lights and other resident needs, but the deficiency was not addressed. The facility's Resident Rights policy emphasized the importance of residents' rights to communication and access to services, which was not upheld in this instance.
Failure to Provide Adequate Fall Prevention Measures
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who was reviewed for accidents. The resident, who had a history of falls and was severely cognitively impaired, fell from her bed and was found face down on the floor with a bruise on her forehead. At the time of the fall, the resident did not have a fall mat placed on both sides of her bed, which was a necessary intervention to prevent injury from falls. The resident's care plan, which was updated after the incident, initially did not include orders for fall mats as a fall intervention. The facility's staff, including the Director of Nursing and the Regional Compliance Nurse, acknowledged that a fall mat was only placed on one side of the bed, leaving the resident at risk of injury. Interviews with staff revealed that the resident was often combative, required a mechanical lift for transfers, and that the bed was not against the wall to facilitate staff assistance. The facility's Fall Risk Assessment policy emphasized the need for appropriate interventions to be addressed immediately on the interdisciplinary plan of care. However, the lack of a fall mat on both sides of the resident's bed was a significant oversight. The incident was unwitnessed, and the resident was found by a CNA during routine rounds. The facility's failure to implement adequate fall prevention measures contributed to the resident's fall and subsequent injury.
Resident Suffers Burn Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who suffered a burn blister on her left wrist. The incident occurred when the resident, who had severe cognitive impairment and required supervision for eating, spilled hot coffee on herself in the dining room. The resident was wearing gloves to prevent scratching her skin, which caused her to lose grip of the cup, resulting in the spill. The resident did not report the incident immediately as she did not feel pain at the time and only noticed the blister later when it started to itch. The resident had a history of cerebrovascular accident, transient ischemic attack, and non-Alzheimer's dementia, which contributed to her need for supervision. The facility's investigation revealed that the resident had gone to the dining room after breakfast to get another cup of coffee and spilled it due to her gloves. The coffee temperature logs indicated that the coffee was served at the correct temperature, but the resident's cognitive impairment and physical limitations were not adequately addressed to prevent the accident. The facility's care plan for the resident included interventions to prevent burns from hot liquids, such as ensuring the coffee was not served over 140 degrees Fahrenheit and that the resident should be seated in an upright position with a table when consuming hot liquids. However, these interventions were not effectively implemented, leading to the resident's injury. The facility's failure to provide adequate supervision and assistance devices for the resident resulted in the burn incident.
Improper Storage of Razors in Shower Room
Penalty
Summary
The facility failed to ensure that disposable razors in one of the shower rooms were kept out of reach of residents, which could potentially lead to accidents or injuries. During an observation and interview, it was noted that two navy blue disposable razors were placed on top of the sharps container in the shower room, making them accessible to residents. CNA A confirmed that razors should be locked in a closet within the shower room and discarded in the sharps container after use. However, the razors were left on top of the sharps container, posing a risk to residents who might use them unsupervised, potentially leading to self-harm or harm to others. Further interviews with RN B and the ADON revealed that CNAs were responsible for showering and shaving residents and were expected to dispose of razors properly after use. RN B acknowledged the risk of infection and injury if razors were not disposed of correctly. The ADON confirmed that all staff were responsible for ensuring razors were placed in the sharps container and expressed uncertainty about why the razors were left out. The facility's policy on shaving indicated that all articles should be stored appropriately, yet this protocol was not followed, leading to the deficiency.
Failure to Designate Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis for 53 out of 65 days reviewed. This deficiency was identified during an interview with the Administrator, who confirmed that the last dedicated DON was in place on 04/12/24. Since then, the responsibilities of the DON have been divided among the Assistant Director of Nursing (ADON), the MDS Coordinator, and the Regional Compliance Nurse, none of whom were dedicated to the DON position for 8 hours a day. The Administrator admitted to not having a policy regarding DON coverage, and the ADON confirmed that she, along with the MDS Coordinator and the Regional Compliance Nurse, were covering the DON duties while also performing their regular roles.
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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