Focused Care Of Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Center, Texas.
- Location
- 501 Timpson, Center, Texas 75935
- CMS Provider Number
- 675398
- Inspections on file
- 28
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Focused Care Of Center during CMS and state inspections, most recent first.
A staff member misused food debit cards intended for several residents, making unauthorized personal purchases and failing to follow facility policy for secure storage and proper use. The affected residents had various cognitive and physical impairments, and the misappropriation was uncovered after a staff member found a card depleted when attempting to shop for a resident.
Surveyors observed significant dirt, grease, and food debris buildup on kitchen floors, walls, equipment, and vents, with staff interviews confirming that cleaning was often delayed until the end of shifts despite a cleaning schedule. These unsanitary conditions were present even though cleaning logs and policies were in place, indicating a failure to consistently maintain kitchen cleanliness and sanitation.
Staff did not close window blinds while providing personal care to a resident with severe cognitive impairment and incontinence, despite training and competency requirements to do so. The resident's room was visible from outside, and both CNAs acknowledged the oversight, which was confirmed by facility leadership as a breach of expected privacy practices.
A shower room was found to be consistently dirty, with a black substance on the walls and floors, cracked tiles, missing or detached baseboards, and a dirty towel left on the floor. Staff interviews confirmed that these issues had been present for an extended period, and maintenance and cleaning had not been prioritized, resulting in an unsanitary and uncomfortable environment.
A vial of tuberculin skin testing (TST) solution was found in the medication refrigerator past its 30-day expiration period, with no staff initials or clear open date, in violation of facility policy and manufacturer instructions. The ADON and DON confirmed responsibility for labeling and discarding multi-dose vials, but the expired TST remained available for use.
A CNA did not perform hand hygiene between handling meal trays for multiple residents, including entering rooms, setting up trays, and assisting with meal setup, without washing or sanitizing hands. Facility leadership confirmed that this practice did not follow the established hand hygiene policy, which requires hand hygiene before and after resident care and after contact with potentially contaminated surfaces.
The facility did not enforce its smoking safety policies in a designated area, as a fire can was found containing cigarette butts, a plastic bottle, and an empty cigarette package, with no ashtray present. Staff interviews confirmed that both housekeeping and supervisory staff were responsible for ensuring the fire can was used properly, but the observed practice did not align with the facility's policy requiring noncombustible ashtrays and proper disposal of cigarette butts.
The facility did not post accurate and current daily nurse staffing information for two consecutive days, as required by policy. Observations showed outdated postings, and interviews with the ADON and DON confirmed the lapse in updating the staffing census, leaving residents and visitors without access to current staffing details.
Multiple residents with behavioral and cognitive challenges were involved in repeated physical and verbal altercations, including fighting, hitting with a walker, and kicking, despite existing care plans and staff awareness of ongoing behavioral issues. The facility did not effectively prevent or intervene in these incidents, resulting in a pattern of abuse and neglect.
A resident with a history of behavioral and mental health issues repeatedly engaged in verbal and physical altercations with other residents, including inappropriate touching and aggression. Despite ongoing incidents and care plan interventions, the facility did not prevent further contact between the resident and others during investigations, nor did it provide evidence of thorough investigation or immediate protective measures. This resulted in continued risk of abuse and mistreatment for multiple residents.
Two residents with severe cognitive impairment and a history of wandering were able to leave the facility unsupervised—one through an unsecured courtyard gate after lawn care services, and another by following a family member out the front door. Staff interviews and record reviews revealed inconsistent monitoring and documentation of exit doors and gates, as well as confusion about relocking procedures, resulting in lapses that allowed the residents to elope.
The facility did not maintain an effective pest control program in the kitchen, as evidenced by the presence of dead insects on food storage shelves and walls, and ongoing reports of roaches by staff over several months. Despite staff reporting the issue to the Dietary Manager and ADM, the problem persisted, and immediate action was not taken until the scheduled pest control visit.
A resident with dementia, hemiplegia, and a history of falls was found in bed without access to their call light after receiving personal care from a CNA, despite facility policies and care plans requiring call lights to be left within reach. Staff interviews confirmed the expectation that call lights be accessible, but this was not followed, resulting in a deficiency related to reasonable accommodation of resident needs.
The facility did not immediately report two separate incidents of resident-to-resident abuse to the state agency as required. In both cases, staff intervened and documented the events internally, but failed to notify authorities within the mandated timeframe, despite being aware of the behavioral risks and history of the residents involved.
A facility failed to develop a complete baseline care plan for a resident, omitting critical interventions such as a fall mat and bed positioning, despite the resident's high risk for falls and severe cognitive impairment. Staff interviews revealed that the oversight occurred due to a high volume of admissions and the hospitalization of the DON, leading to a gap in care. The facility's policy mandates baseline care plans within 48 hours of admission, which was not met in this instance.
The facility's kitchen had unsanitary conditions, including buildup on floors and equipment, undated and expired food items, and improper labeling. Staff interviews revealed confusion about cleaning schedules and responsibilities, despite previous training.
The facility failed to ensure proper labeling and storage of glucometer strips and glucose control solutions, leading to potential inaccuracies in glucose testing. Staff demonstrated confusion and lack of training regarding the expiration and proper use of these materials.
The facility failed to maintain an effective training program for five employees, including the Administrator and various directors, who did not receive required annual training on restraint reduction and fall prevention. This deficiency was identified through record reviews and staff interviews, revealing gaps in the training process and oversight responsibilities, potentially placing residents at risk.
The facility failed to ensure a resident's call light was within reach on multiple occasions, despite staff training and awareness of its importance. The resident, who has a history of falls, was unable to access her call light, posing a risk to her safety.
A resident with Alzheimer's experienced discomfort due to their room temperature dropping to 67°F. The facility's maintenance director confirmed that temperatures should be maintained between 71°F and 81°F, but staff adjustments led to inconsistent temperature control. The administrator acknowledged the issue and committed to closer monitoring.
The facility failed to complete baseline care plans within 48 hours of admission for two residents, leading to potential care delays and risks. Interviews revealed that the process involved multiple staff members, but the DON admitted to being behind, and there was no specific policy to ensure timely completion.
A resident with severe cognitive impairment and multiple diagnoses did not receive necessary assistance with personal hygiene, specifically shaving, despite expressing discomfort and requesting help. Staff failed to notice and address the resident's unwanted facial hair, highlighting a lapse in adherence to care plans and responsibilities.
A resident with multiple diagnoses and significant weight loss did not consistently receive prescribed health shakes, leading to a risk of unplanned weight loss and malnutrition. Staff interviews and observations revealed discrepancies in the dietary system and a lack of adherence to physician orders.
The facility failed to conduct annual competency evaluations for CNAs, specifically for CNA G, due to a COVID outbreak and a shift in focus. This lapse could lead to risks such as cross-contamination, infections, safety issues, falls, and injuries.
The facility failed to document the required number of witness signatures for drug destruction in January and February 2024. The drug destruction records were only signed by one witness and the consultant pharmacist, instead of the required two witnesses, increasing the risk of drug diversion.
The facility failed to maintain an effective infection control program, as evidenced by two CNAs not following proper hand hygiene and glove-changing protocols during incontinent care for two residents. Despite recent training and competency evaluations, the CNAs' actions highlighted significant lapses in infection prevention practices.
The facility failed to provide mandatory infection control training to a newly hired CNA. Interviews revealed that the facility relied on corporate for training materials and did not have a formal policy, leading to gaps in the training process. This oversight could result in a knowledge deficit among staff.
The facility failed to provide the required compliance and ethics training for one of its employees, CNA J, who was hired on 3/5/2024. Interviews revealed that the facility relied on corporate to send out the required trainings, but there was a lack of follow-up to ensure all staff received the necessary education. The facility did not have a designated person for HR duties in-house, and there was no policy on staff training, leading to gaps in compliance and ethics education.
Misappropriation of Resident Food Debit Cards by Staff
Penalty
Summary
The facility failed to ensure residents' right to be free from misappropriation of property for five residents who participated in a food debit card program. The program, funded by an insurance company, provided eligible residents with a $100 monthly benefit to purchase food items. Some residents kept their cards, while others had them stored in the business office, where staff could access them to shop on behalf of the residents. The facility had a policy requiring the cards to be securely stored and only accessible by the resident, their responsible party, or the community Life Enrichment Director (LED), with a sign-out log and receipts maintained for all transactions. Despite these policies, the Business Office Manager (BOM) admitted to using the food debit cards of multiple residents for personal purchases on several occasions. Receipts and interviews confirmed that the BOM made unauthorized purchases using the cards of at least five residents, including items not intended for the residents' benefit. The purchases were made on multiple dates, and the total amount misappropriated was $670.22. The BOM acknowledged that she used the cards for her own benefit, particularly at the end of the month when unspent funds would not roll over, and admitted that she knew her actions were wrong and constituted theft. The residents affected had varying degrees of cognitive impairment, including dementia, Alzheimer's disease, and intellectual disabilities, with some requiring supervision or assistance with daily living activities. The misappropriation was discovered after a staff member attempted to use a resident's card and found it had insufficient funds, prompting a review of recent transactions and subsequent investigation. The facility's failure to adhere to its own policies and procedures regarding the secure handling and authorized use of resident food cards led to the misappropriation of resident property.
Failure to Maintain Kitchen Cleanliness and Sanitation
Penalty
Summary
The facility failed to maintain proper cleanliness and sanitation in the kitchen, as evidenced by observations of dirt, grease, food debris, and dust on floors, baseboards, walls, equipment, and air vents in the kitchen and dry storage areas. These unsanitary conditions were noted during multiple observations, with visible buildup on the floor, baseboards, walls near the washing station and steam table, the top of the dishwashing machine, and air vents. Staff interviews confirmed that kitchen staff were responsible for cleaning, but admitted that cleaning was sometimes delayed until the end of shifts due to workload, despite the existence of a cleaning schedule and assigned tasks. Record reviews showed that monthly cleaning logs were completed for the previous three months, and the facility had a policy assigning cleaning responsibilities to Food and Nutrition Services Personnel. However, the observed conditions indicated that cleaning was not consistently performed throughout the shift as required. Staff and management acknowledged that the kitchen was not always kept clean during operations, and that the current state of the kitchen could lead to food contamination.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
Staff failed to ensure privacy and dignity for a resident during personal care by not closing the window blinds while providing care. During an observation, two CNAs performed personal care for a resident with severe cognitive impairment, incontinence, and multiple chronic conditions, including COPD, diabetes, major depressive disorder, and heart failure. Although the door was closed and the privacy curtain was pulled, the window blinds remained open, and a car passed by outside during the care. Both CNAs acknowledged in interviews that they should have closed the blinds, and their competency evaluations included instructions to do so for privacy during care. The resident stated that she did not want anyone seeing her during care, although she did not notice the blinds were left open on the day in question. Interviews with facility leadership, including the ADON, DON, and Administrator, confirmed that staff are expected to provide privacy by closing doors, pulling curtains, and closing window blinds during personal care. Observations from outside the facility showed that the resident's room was visible from the parking lot when the blinds were up. The facility did not have a specific policy on dignity, but staff training and competency evaluations required providing privacy, including closing blinds during care.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in one of two shower rooms (Hall 100), as evidenced by multiple observations and staff interviews. Residents reported during a council meeting that the shower room was consistently dirty, with clothes and feces on the floor. Direct observation revealed a black substance on the walls and floors of one shower stall, cracked tiles, missing or detached baseboards, and a dirty towel left on the floor. Housekeeping staff confirmed that the black substance had been present since their employment began and that the baseboards were not properly attached. The Housekeeping Supervisor acknowledged the presence of the black substance, believed to be glue from missing baseboards, and noted the need for tile replacement and repairs. The Maintenance Supervisor identified the black substance as mildew and confirmed the need for deep cleaning and resealing, but stated that repairs had not been prioritized. The Administrator was aware of the issues in the shower room, including the inappropriate baseboards, cracked tiles, and overall uncleanliness. Facility policy requires a clean, sanitary, and orderly environment, but the observed conditions did not meet these standards. The lack of timely cleaning, maintenance, and repair contributed to the ongoing unsanitary and unsafe environment in the Hall 100 shower room.
Expired Tuberculin Solution Not Discarded as Required
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not removing an expired vial of tuberculin skin testing (TST) solution from the vaccine/medication refrigerator. During an observation, a vial of TST solution was found with an open date of 4/24, lacking staff initials, and had not been discarded after the required 30-day period as indicated by both facility policy and the manufacturer's instructions. The ADON confirmed that the TST was administered to residents and staff as needed, and acknowledged that the vial should have been discarded after 30 days, but the lack of initials and a clear open date made it impossible to verify compliance. Interviews with the ADON, DON, and Administrator revealed that responsibility for labeling and discarding multi-dose vials rested with the ADON and DON. The DON stated that failure to discard expired medications could result in ineffective vaccinations or false test results. The facility's policy required nurses to label multi-dose vials with the date opened and discard them after 30 days unless otherwise specified. The TST package insert and FDA guidance also specified disposal after 30 days of opening, which was not followed in this instance.
Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to perform proper hand hygiene while distributing meal trays to residents on Hall 500. During an observation, the CNA did not wash or sanitize her hands before entering or exiting resident rooms or between handling meal trays for multiple residents. The CNA entered several rooms, set up meal trays, opened utensils, repositioned a resident, and assisted with meal setup, all without performing hand hygiene between residents. These actions were directly observed and documented during the meal service. Interviews with facility leadership, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, confirmed that staff are expected to sanitize their hands between residents when passing trays, as outlined in the facility's hand hygiene policy. The policy specifies that hand hygiene should be performed before and after providing any type of care and after contact with potentially contaminated surfaces. The failure to follow these procedures was acknowledged by facility leadership during interviews.
Failure to Enforce Smoking Safety Policies in Designated Area
Penalty
Summary
The facility failed to formulate, adopt, and enforce adequate policies regarding smoking, smoking areas, and smoking safety, specifically in the secured unit smoking area. During an observation, a fire can in the designated smoking area was found to contain not only cigarette butts but also a plastic bottle and an empty cigarette package, and there was no ashtray present. Staff interviews revealed that housekeeping was responsible for cleaning the fire can daily, and staff supervising smokers were expected to ensure that only cigarette butts were placed in the fire can. However, both housekeeping and supervisory staff acknowledged that trash in the fire can was a fire hazard and that the area should be regularly inspected for fire hazards before and after smoke breaks. A review of the facility's smoking policy indicated that smoking by residents was allowed only with specific safety measures, including the use of noncombustible ashtrays and metal containers with self-closing covers for ash disposal. Despite this policy, the observed practice did not align with these requirements, as there was no ashtray in the area and inappropriate items were found in the fire can. This failure to follow established policy and maintain a safe smoking environment constituted a deficiency in the facility's safety practices.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted and readily accessible to residents and visitors for two consecutive days. Observations on both days revealed that the staffing census information displayed was outdated, showing the date from two days prior rather than the current day. Interviews with the ADON and DON confirmed that they were responsible for posting the daily staffing information but acknowledged that the postings for the reviewed days were not updated as required. The ADON was unsure why the posting was not updated, and the DON admitted to forgetting to post the information. The facility's policy requires that the number of licensed nurses and unlicensed nursing personnel responsible for resident care be posted daily within two hours of each shift's start, in a prominent and accessible location. Despite this policy, the required information was not posted for the days reviewed, and staff responsible for the postings confirmed the lapse. No information was provided regarding any residents' medical history or condition at the time of the deficiency.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in multiple resident-to-resident altercations and incidents of physical and verbal aggression. Several residents with varying degrees of cognitive and physical impairment were involved in these incidents. For example, one resident with bipolar disorder, impulse disorder, and Parkinson's disease was involved in multiple altercations, including fighting with another resident in the smoking area, being hit with a walker by a different resident in the dining room, and kicking a resident with severe cognitive impairment during breakfast. These events were often preceded by arguments, verbal aggression, or behaviors such as instigating conflicts and making inappropriate comments. Another resident with vascular dementia and hemiplegia was involved in a physical altercation in the smoking area, where both he and another resident ended up on the ground after an argument escalated. The care plans for these residents included interventions such as monitoring for signs of danger, psychological evaluations, and staff supervision, but these measures were not effective in preventing the altercations. In one case, a resident with severe cognitive impairment and hemiplegia was threatened and grabbed by another resident, and later kicked by a different resident, despite care plan interventions intended to prevent such incidents. Interviews with residents and staff revealed a pattern of ongoing behavioral issues, with one resident frequently instigating arguments and being verbally aggressive toward others. Staff and residents reported that this individual had a history of behavioral problems, including being physical with other residents and making inappropriate comments. Despite being aware of these behaviors and having care plans in place, the facility did not prevent repeated incidents of abuse and altercations among residents, leading to the identification of an Immediate Jeopardy situation.
Removal Plan
- All staff in-serviced by Executive Director of Operations (EDO)/Director of Clinical Operations (DCO) and/or designee on the following topics: Prevention, Identification and Reporting/Investigation of Abuse; How to Immediately Protect Residents when abuse is suspected; Possible Interventions to Assist with De-escalation after an Incident. All staff not present at time of in-service will not be permitted back to work until in-service is complete.
- Resident #3 was placed on one-to-one monitoring. Discharge Planning initiated to family. Resident remained on one-to-one monitoring until discharge.
- Safe Surveys were conducted by DRSS and/or designee with all residents cognitively able to participate. Action taken based on survey results, including care plan and task updates and one-on-one in-service for CNA as needed.
- All residents identified as at risk for physically aggressive behaviors were reviewed by the CRC/ADCO to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services.
- The DCO/ADCO/EDO will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting.
- Abuse allegations will be reported and investigated according to company policy and THHS regulations. Potential abuse or situations requiring further investigation will be documented on a Grievance form with any investigation documentation attached.
- All staff in-serviced on the Grievance process and utilizing the Grievance form to document the potential abuse or situation and the investigation.
- The Medical Director was made aware of the immediate jeopardy and involved in the development of the plan to remove during an abbreviated QA. Next scheduled QA meeting set.
- Monitoring of the Plan of Removal will be conducted through personal observation, through completion by Regional President of Operation and Regional Director of Clinical Services.
Failure to Prevent and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that further incidents were prevented during the investigation process. Specifically, three residents were involved in multiple altercations, both verbal and physical, with one resident repeatedly instigating arguments, making inappropriate comments, and engaging in physical aggression toward other residents. Despite documented behavioral issues and previous incidents, the facility allowed the alleged perpetrator to remain in the facility and have direct contact with other residents, including those who had previously been involved in altercations with him. The records show a pattern of behavioral problems, including verbal aggression, inappropriate touching, and physical altercations involving the same resident. This resident had a history of mental health diagnoses, including bipolar disorder and impulse disorder, and had been the subject of multiple care plan interventions and counseling referrals. However, the interventions implemented were not sufficient to prevent further incidents, as the resident continued to have direct contact with others and was involved in additional altercations, including kicking another resident and engaging in fights during smoke breaks and in the dining area. Other residents and staff reported ongoing issues with this resident, describing him as an instigator who frequently caused disruptions and conflicts. The facility's documentation and interviews indicate that, although some assessments and care plan updates were made following incidents, there was a lack of effective action to prevent further abuse or mistreatment while investigations were ongoing. The facility did not ensure the separation of the alleged perpetrator from potential victims, and there was insufficient evidence of thorough investigation or immediate protective measures. This failure resulted in an Immediate Jeopardy situation, as residents remained at risk for further harm due to the continued presence and actions of the resident with a history of aggressive and inappropriate behavior.
Removal Plan
- All staff in-serviced by Executive Director of Operations/Director of Clinical Operations and/or designee on Prevention, Identification and Reporting/Investigation of Abuse. All staff not present at time of in-service will not be permitted back to work until in-service is complete.
- The Executive Director of Operations/Director of Clinical Operations were in-serviced by the Regional Director of Clinical Operations on Prevention, Identification and Reporting/Investigation of Abuse.
- Resident #3 was placed on one-to-one monitoring.
- Discharge Planning initiated to family for Resident #3. Family agreed by phone to discharge resident to their care. Resident remained on one-to-one monitoring until discharge.
- Safe Surveys were conducted by Director of Resident Support Services and/or designee with all residents cognitively able to participate. Action taken based on survey results included: Resident #3 was on one-on-one monitoring; resident with wound care concern no longer in facility; resident who reported CNA roughness was reinterviewed, care plan and tasks updated, and one-on-one in-service to be completed with CNA.
- All residents identified as at risk for physically aggressive behaviors were reviewed by the Clinical Resource Coordinator/Assistant Director of Clinical Operations to ensure they had an accurate care plan, appropriate interventions and appropriate Psych Services or Counseling Services.
- The Director of Clinical Operations/Assistant Director of Clinical Operations/Executive Director of Operations will monitor EMR documentation including the 24-hour report, incident reports and alerts, and Grievances to identify potential abuse or situations requiring further investigation during morning meeting.
- Abuse allegations will be reported and investigated according to company policy and THHS regulations.
- Potential abuse or situations requiring further investigation will be documented on a Grievance form.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Security
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Two residents with severe cognitive impairment and a history of wandering or elopement risk were able to leave the facility unsupervised. One resident, who had dementia and was assessed as high risk for elopement, exited the secured unit courtyard through an unlocked gate after lawn care services had been performed. The resident was found by a community member at a nearby doctor's office and returned to the facility. Staff interviews and observations revealed that the gate required manual relocking after use, and staff were responsible for ensuring it was secured, especially after vendors such as lawn care services accessed the area. Another resident, also with severe cognitive impairment and a history of attempts to leave the facility, exited through the front door by following a family member who did not close the door behind them. This resident was found by a passerby at a nearby intersection and returned to the facility. Review of surveillance footage and staff interviews confirmed that the resident left the building during a period when staff were in a meeting and was not immediately noticed missing. The resident's care plan indicated interventions for wandering, but these were not effective in preventing the elopement. Record reviews and staff interviews indicated inconsistent practices regarding the monitoring and securing of exit doors and gates. Staff were expected to check the gates and doors at regular intervals and document these checks, but documentation was missing for certain periods. There was also confusion among staff regarding the procedures for relocking gates and the use of emergency exit buttons. The facility's elopement policy required prompt investigation and search for missing residents, but lapses in supervision and environmental security allowed two residents to leave the premises unsupervised.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, resulting in the presence of roaches. Observations revealed dead insects on dry-food storage shelves and on the walls below a food preparation area. Staff interviews confirmed that roaches had been present in the kitchen for at least a month, and the issue had been reported to both the Dietary Manager and the Administrator (ADM). Despite these reports, the problem persisted, with staff indicating that roaches had been an ongoing issue since December of the previous year. The Dietary Manager acknowledged the ongoing roach problem and stated that pest control had only visited on the day of the survey. The ADM confirmed that roaches had been seen in the kitchen walls during maintenance work and that staff had used a can of pesticide rather than contacting pest control immediately, as a routine visit was already scheduled for the following week. Review of pest control service records showed that pest control products were applied in various areas of the facility, with a follow-up visit recommended. The facility's pest control policy, last revised in 2008, requires an ongoing program to keep the building free of pests, which was not effectively implemented in this instance.
Failure to Ensure Call Light Accessibility for Resident with Mobility Impairments
Penalty
Summary
A deficiency was identified when a resident with dementia, hemiplegia, hemiparesis, and a history of falls was found in bed without their call light within reach. The resident, who was dependent on staff for most activities of daily living except eating and was always incontinent of bladder with an ostomy, reported that a CNA had assisted with personal care and left the call light on the unoccupied bed, making it inaccessible. The resident was unable to stand or walk independently and relied on a trapeze bar to sit up in bed. Interviews with staff confirmed that CNAs were responsible for ensuring call lights were accessible to residents before leaving the room. The facility's care plan for the resident included an intervention to ensure the call light was within reach and answered promptly, and the facility policy required all resident rooms to be equipped with a call system for staff assistance. Despite these expectations and policies, the call light was not left within reach, resulting in a failure to reasonably accommodate the resident's needs and preferences.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation was made, as required by regulation and facility policy. Specifically, the facility did not promptly report two separate incidents of resident-to-resident abuse to the appropriate state authorities. In the first incident, two residents engaged in a physical altercation in the smoking area, with both residents exchanging slaps and falling to the ground. Staff intervened, redirected the residents, and assessed for injuries, but the event was not reported to the state agency within the required timeframe. In the second incident, a resident with a history of behavioral issues and multiple psychiatric diagnoses kicked another resident multiple times during breakfast. The incident was documented by nursing staff and reported internally to the DON, but again, the required immediate external reporting to the state agency did not occur. The resident who was kicked had severe cognitive impairment and required substantial assistance with transfers. Interviews with staff and residents confirmed the altercations and the behavioral history of the resident involved in both incidents. Record reviews and staff interviews further revealed that the facility was aware of the behavioral risks associated with the resident involved in both incidents, including previous altercations, psychiatric hospitalizations, and unsuccessful attempts to secure alternative placement. Despite these known risks and the facility's policy requiring immediate reporting of abuse allegations, the facility did not follow established procedures to notify the state agency within the mandated timeframe for either incident.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions for effective and person-centered care. Specifically, the baseline care plan did not address the use of a fall mat at the bedside and the bed being in the lowest position, which were critical interventions for the resident who was at high risk for falls. The resident, a female with severe cognitive impairment and multiple health issues including acute osteomyelitis, muscle wasting, and pressure ulcers, required these interventions as part of her care plan to prevent injury. Interviews with facility staff revealed that the charge nurse, ADON, and DON were responsible for completing and verifying baseline care plans. However, due to a high volume of admissions and the hospitalization of the DON, the baseline care plan for the resident was incomplete. The ADON acknowledged the oversight and emphasized the importance of baseline care plans in ensuring staff are aware of residents' needs. The facility's policy required baseline care plans to be completed within 48 hours of admission, but this was not adhered to in this case, resulting in a gap in care for the resident.
Sanitation Issues in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. The kitchen floor, walls, and refrigerator handles had a buildup of a sticky substance. A fan in the kitchen had a dark thick substance on its blades and cover. The drink dispenser had undated boxes of concentrate liquid, with one box of orange liquid concentrate lying on the floor. The coffee dispenser had undated boxes of coffee concentrate and a dried dark brown substance inside. The kitchen refrigerator contained unlabeled and expired items, including cottage cheese, cranberry sauce, an unlabeled meat link, a bottle of red sauce, and other unlabeled substances. Interviews with the cook and dietary manager revealed that staff were responsible for checking the refrigerator daily for unlabeled and expired items, but there was confusion about the cleaning schedule for the drink dispensers. The dietary manager confirmed that the kitchen staff had been trained on maintaining sanitary conditions and that there was a cleaning schedule in place. However, the administrator acknowledged that more training would be necessary to ensure compliance. Record reviews indicated that full cleaning was performed sporadically, and staff had been trained on dating, labeling, and deep cleaning the kitchen.
Improper Labeling and Storage of Glucometer Strips and Solutions
Penalty
Summary
The facility failed to ensure drugs and biologicals were labeled and stored according to professional principles, specifically regarding glucometer strips and glucose control solutions. During observations, it was found that three vials of glucometer strips on the 500-hallway medication cart were open without an opened date, and expired high and low glucose check solutions were not discarded. Interviews with LVN A and the ADON revealed that the staff had received training on the new process for labeling and checking glucometer strips, but there was confusion about the duration for which the strips and solutions were valid after opening. LVN B and LVN C also demonstrated a lack of knowledge about the proper use and expiration of these materials, indicating gaps in training and adherence to the new process. Further observations on the 600-hallway medication cart showed that the glucose control solutions were labeled with an opened date, but LVN B was unsure of the expiration period. On the 200-hallway medication cart, there were no glucose control solutions present, and LVN C, who had only been at the facility for two days, had not received training on the proper procedures. The Administrator and DON acknowledged their responsibility for staff training and compliance but confirmed that expired solutions and undated strips could lead to inaccurate glucose testing results. Record reviews supported the need for proper labeling and timely discarding of these materials to ensure accurate readings and resident safety.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for five of fourteen employees reviewed for training. Specifically, the Administrator, Director of Resident Support Service, Director of Life Enrichment, DM, and CNA J did not receive required annual training on restraint reduction and fall prevention. This deficiency was identified through record reviews and interviews with facility staff, revealing gaps in the training process and oversight responsibilities. The lack of training could place residents at risk of not receiving appropriate care to maintain their highest practicable physical, mental, and psychosocial well-being. Record reviews indicated that the Administrator, hired on 6/21/2022, and the Director of Resident Support Service, hired on 11/3/2022, did not receive annual training on restraints. Similarly, the Director of Life Enrichment, hired on 7/26/2021, also lacked this training. The DM, hired on 10/13/2022, did not receive annual training on both fall prevention and restraints, while CNA J, hired on 10/4/2022, missed annual training on fall prevention. Interviews with the BOM, HR Business Partner, Director of Clinical Education, DON, and Administrator highlighted that the facility relied on corporate to send out training requirements and that there was an oversight issue with the email communication regarding restraint training. The Director of Clinical Education admitted that there was no policy on staff training and that an email sent on June 2, 2023, only included nursing staff for restraint training, excluding other necessary personnel. The DON and Administrator confirmed that they followed the list of trainings sent by corporate and were unaware of any deficiencies until the survey. The lack of a designated HR person in-house and reliance on corporate for training oversight contributed to the failure in ensuring all staff received the required annual training, potentially leading to a knowledge deficit among staff members.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that Resident #58's call light was within reach on multiple occasions, specifically on 5/13/2024 and 5/14/2024. Resident #58, who is [AGE] years old and has a diagnosis of intervertebral disc degeneration, was observed to have her call light hanging on a monitor across the room, making it inaccessible. Despite being awake and alert, Resident #58 was unable to locate her call light and expressed that she would have to yell for help if needed. This issue was observed during different times of the day, indicating a consistent failure to ensure the call light was within reach as required by her comprehensive care plan dated 4/24/2024, which noted her history of falls and the necessity of having the call light within reach. Interviews with staff, including a CNA, LVN, DON, and the administrator, revealed that all staff were aware of the importance of keeping call lights within reach and had been trained on this matter. The CNA mentioned that it was everyone's responsibility to check call lights during their rounds, while the LVN and DON reiterated that staff should ensure call lights are in place each time care is provided. Despite this training and awareness, the facility did not have a specific policy for call light placement, leading to the oversight and potential risk to Resident #58 and other residents who rely on their call lights to notify staff of their needs.
Failure to Maintain Safe and Comfortable Temperature Levels
Penalty
Summary
The facility failed to provide comfortable and safe temperature levels for a resident, resulting in the room temperature dropping to 67°F. The resident, who has Alzheimer's and moderate cognitive impairment, expressed discomfort and distress due to the cold temperature. The maintenance director confirmed that the temperature should be maintained between 71°F and 81°F for resident health and adjusted the air to bring the temperature back within the acceptable range. However, it was noted that staff would sometimes adjust the temperature based on individual resident complaints without considering the overall impact on other residents. The administrator acknowledged that the maintenance department was responsible for maintaining the correct temperatures but admitted that staff adjustments were not always monitored. The facility's policy indicated that temperatures should be kept between 71°F and 81°F, but this was not consistently enforced. The maintenance director and a CNA both noted that improper temperature regulation could negatively affect residents' health and comfort. The administrator committed to monitoring the situation more closely and placing a thermometer in the resident's room to ensure compliance with temperature regulations.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for each resident within 48 hours of admission, as required by regulations. Specifically, Resident #58 and Resident #61 did not have their baseline care plans completed within the mandated timeframe. Resident #61, who was admitted with encephalopathy, did not have a baseline care plan completed until several days after admission. Similarly, Resident #58, admitted with intervertebral disc degeneration, also experienced a delay in the completion of her baseline care plan. Both residents were at risk of not receiving the correct and necessary care due to these delays. Interviews with facility staff, including an LVN, the clinical reimbursement coordinator, the DON, and the administrator, revealed that the process for completing baseline care plans involved multiple steps and personnel. However, the DON admitted to being behind on completing these care plans, and there was no specific policy in place to ensure timely completion. The facility's admission checklist did indicate the need to initiate a baseline care plan and provide a summary to the resident or their representative, but this was not consistently followed, leading to potential care delays and risks for the residents involved.
Failure to Maintain Personal Hygiene for Resident
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and major depressive disorder. The resident required assistance with personal hygiene tasks, including shaving, but was observed with unwanted facial hair on multiple occasions. Despite the resident expressing discomfort and requesting help to remove the facial hair, the staff did not address this need adequately. The care plan indicated that the resident required set-up assistance and verbal cues for personal hygiene, but this was not consistently provided. Interviews with staff revealed that the nurse aides were expected to shave residents on their assigned shower days, but this task was not completed for the resident in question. The CNA responsible for the resident admitted to not noticing the facial hair and failing to remove it during the resident's shower. The DON and Administrator acknowledged the oversight and the lack of a specific policy on ADL care, indicating that the nursing staff should ensure that residents receive appropriate care. The deficiency highlights a lapse in the facility's adherence to care plans and staff responsibilities, resulting in the resident's unmet personal hygiene needs.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for Resident #33, who was admitted with multiple diagnoses including acute chronic respiratory failure, hypertension, type 2 diabetes, and COPD. The resident had physician orders for dietary supplements, specifically health shakes, to address weight loss and poor oral intake. Despite these orders, the facility did not consistently provide the health shakes as prescribed, leading to a risk of unplanned weight loss and malnutrition for the resident. Observations and interviews revealed that the resident did not receive the health shakes at lunch on multiple occasions, and there was a discrepancy in the dietary sticker sheet, which only listed the resident for shakes at breakfast and supper, not lunch. Interviews with staff, including a CNA, dietary aide, and the Dietary Manager (DM), confirmed that the resident was supposed to receive health shakes three times a day but often did not receive them as ordered. The CNA mentioned that the dietary staff did not always place the shakes on the trays, requiring nursing staff to retrieve them from the kitchen. The dietary aide was unsure about the resident's supper shake and admitted that some residents were given shakes only if they did not eat. The DM acknowledged that the resident was missed at lunch on the observed date and explained that the system in place relied on stickers to identify residents needing health shakes. The Director of Nursing (DON) and the Administrator both confirmed the process for implementing dietary orders, which involved communication between the Registered Dietitian (RD), DON, and DM. The DON noted that the resident had experienced significant weight loss and that the health shakes were intended to stabilize her weight. The Administrator was unaware of the issue but recognized the risk of not providing the ordered supplements. The facility did not have a specific policy on dietary orders or recommendations, contributing to the inconsistency in providing the prescribed nutritional supplements.
Failure to Conduct Annual Competency Evaluations for CNAs
Penalty
Summary
The facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, specifically for CNA G, who was hired on 1/17/2023. There was no evidence of a competency evaluation for CNA G in the past 12 months, with the last evaluation being on 1/17/2023. The Assistant Director of Nursing (ADON) acknowledged that skill check-offs were conducted annually in December, but due to a COVID outbreak in November 2023, some evaluations, including that of CNA G, were not completed. The ADON admitted that this lapse could lead to risks such as cross-contamination, infections, safety issues, falls, and injuries if staff did not have a competency evaluation. The Director of Nursing (DON) confirmed that the ADON was responsible for conducting the yearly competency evaluations and that the facility had not completed the nurse aide evaluations for the current year. The Administrator also acknowledged the oversight, noting that CNA G had changed from a part-time position to a PRN role and that the COVID outbreak had shifted the ADON's focus, preventing the completion of the evaluation. The Administrator admitted that there was a risk of staff not remembering the proper way to perform tasks without a competency evaluation. The facility did not have a policy on competency evaluations, which contributed to the oversight.
Failure to Document Required Witness Signatures for Drug Destruction
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation, and did not follow the policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for two months (January 2024 and February 2024). Specifically, the facility did not document the required number of witness signatures for drug destruction on 01/10/2024 and 02/06/2024. The drug destruction records for these dates were only signed by one witness and the consultant pharmacist, instead of the required two witnesses as per regulation. Interviews with the ADON, Administrator, consultant pharmacist, and DON revealed that the DON is responsible for ensuring compliance with drug destruction procedures and obtaining two witness signatures. The ADON usually assists as the second witness but did not do so for the January and February destructions because the second witness line was blank. The consultant pharmacist confirmed that drug destruction should always be witnessed by herself and two other witnesses. The failure to follow these procedures increased the risk of drug diversion, as noted by the staff during their interviews.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to two residents. CNA D did not change gloves or sanitize/wash hands when providing care to a resident with severe cognitive impairment and incontinence. Specifically, CNA D continued to perform care tasks, including applying a skin barrier and adjusting bed linens, without changing gloves or performing hand hygiene after handling soiled materials. This lapse in protocol was observed during an incident on 5/13/2024, and CNA D acknowledged the mistake during an interview, attributing it to nervousness despite recent training and competency evaluation in hand hygiene and incontinent care procedures. Similarly, CNA H failed to perform hand hygiene before, during, and after providing incontinent care to another resident who required substantial assistance and was always incontinent of bladder and bowel. CNA H was observed removing gloves from her pocket and applying them without sanitizing her hands, and she did not wash or sanitize her hands at any point during the care process. This incident occurred on 5/14/2024, and during a subsequent interview, CNA H admitted to the oversight, citing the absence of her usual hand sanitizer and improper storage of gloves as contributing factors. Despite having passed a hand hygiene competency check earlier in the month, CNA H did not adhere to the established protocols. Interviews with the DON, ADON, and the facility administrator confirmed that the staff had been trained on proper hand hygiene and incontinent care procedures, and that quarterly check-offs were conducted to ensure compliance. However, the observed failures by CNAs D and H to follow these protocols during the provision of care highlighted significant lapses in the facility's infection prevention and control practices, potentially placing residents at risk of exposure to communicable diseases and infections.
Failure to Provide Mandatory Infection Control Training to CNA
Penalty
Summary
The facility failed to provide mandatory training on infection prevention and control to CNA J upon hire. CNA J was hired on 3/5/2024, and her personnel file indicated that she did not receive the required training on infection control. Interviews with various staff members, including the BOM, HR Business Partner, Director of Clinical Education, DON, and Administrator, revealed that the facility relied on corporate to send out training materials and did not have a designated person in-house for HR duties. The Director of Clinical Education mentioned that the facility was in the process of ensuring that orientation and onboarding included additional education on infection control, but this had not been fully implemented at the time of the survey. The facility did not have a policy on required trainings, which contributed to the oversight in providing the necessary training to CNA J. The Administrator and DON both acknowledged that they followed the list of trainings sent by corporate and assumed that all required trainings were being completed correctly. However, the lack of a formal policy and the reliance on corporate for training materials led to gaps in the training process. The facility assessment indicated that all staff should receive training on infection control upon hire, but this was not adhered to in the case of CNA J. The failure to provide this training could potentially result in a knowledge deficit among staff, increasing the risk of the spread of illness among residents.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide the required compliance and ethics training for one of its employees, CNA J, who was hired on 3/5/2024. The personnel file for CNA J indicated that she did not receive the necessary training. Interviews with various staff members, including the BOM, HR Business Partner, Director of Clinical Education, DON, and the Administrator, revealed that the facility relied on corporate to send out the required trainings. However, there was a lack of follow-up to ensure that all staff, including those not present during the initial training sessions, received the necessary education. The facility did not have a designated person for HR duties in-house, and there was no policy on staff training, leading to gaps in compliance and ethics education for new hires and existing staff. The Director of Clinical Education and the DON were responsible for ensuring that the facility received and completed the required trainings sent by corporate. However, the process was not effectively managed, resulting in CNA J missing the compliance and ethics training. The Administrator and other staff members acknowledged the risk of staff not knowing how to handle situations due to the lack of training. The facility's reliance on corporate for training without a robust follow-up mechanism and the absence of a training policy contributed to the deficiency in providing the required compliance and ethics training to CNA J.
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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