Garland Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Garland, Texas.
- Location
- 321 N Shiloh Rd, Garland, Texas 75042
- CMS Provider Number
- 675790
- Inspections on file
- 56
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 6 (1 serious)
Citation history
Health deficiencies cited at Garland Nursing And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to ensure accurate medication administration and proper observation of medication ingestion for three cognitively intact residents. One resident with significant cardiac and bleeding risk factors was ordered a specific nightly dose of Warfarin but was given an additional dose on at least two evenings, after being approached by staff twice during the same medication pass. The resident reported hiding the extra tablets when staff walked away without observing ingestion and later returned them to another CMA, who passed them to an RN; the RN then handed them to an LVN without documenting or discarding them. Two other residents reported that staff did not consistently watch them take their bedtime Melatonin and Zolpidem, and they often held onto these medications until they chose to take them. Interviews with the DON and staff, along with policy review, showed that these practices did not align with facility expectations and written policies requiring administration as ordered, direct observation of ingestion, and documentation and reporting of medication errors.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact care for two residents with pressure ulcers. One resident with severe cognitive impairment and sacral and foot pressure ulcers had EBP signage and a care plan directing staff to wear gowns and gloves, yet an RN and a CNA provided incontinence care and the RN performed wound care wearing only gloves. Another resident with moderate cognitive impairment and sacral and ankle pressure ulcers also had an EBP care plan, but an LVN completed wound care using only gloves. In interviews, staff acknowledged they knew gowns and gloves were required under EBP, cited forgetting and the absence of PPE at the doorway, and recognized that failure to use EBP could lead to cross contamination, while training records showed these staff had not attended the facility’s EBP training.
A resident with a Foley catheter and neuromuscular bladder dysfunction was observed with her catheter bag uncovered and visible from the hallway, contrary to facility policy and staff expectations. Both an LVN and the DON acknowledged that a privacy bag should have been used to maintain the resident's dignity, but it was not in place at the time of observation.
Surveyors found that three residents with significant mobility or cognitive impairments did not have their call lights within reach, despite care plans and facility policy requiring accessibility. Staff interviews confirmed that call lights were often left out of reach after care was provided, and some residents were unaware of their location, potentially preventing them from obtaining assistance when needed.
Two residents requiring respiratory care were found with their nasal cannulas and CPAP mask left unbagged and improperly stored when not in use. Nursing staff and the DON confirmed that respiratory devices should be bagged to prevent infection, and facility policy requires safe handling of such equipment.
A resident with significant neurological and mobility impairments, requiring a two-person Hoyer lift transfer, was improperly transferred by a CNA using a sliding board without assistance or proper training. The resident fell during the transfer, resulting in a head injury and subarachnoid hemorrhage. Facility staff and policy reviews confirmed that only therapy staff were authorized to use sliding boards for this resident, and that the CNA did not follow established protocols.
The facility failed to maintain a clean and homelike environment for residents in 9 of 12 rooms reviewed. Observations showed dirty air vents, stained faucets, and unclean mini fridges. Interviews with housekeeping staff revealed confusion about cleaning responsibilities, and the administrator acknowledged inadequate cleaning and supervision. These deficiencies could impact infection control.
The facility failed to maintain a safe environment for three residents by not adhering to fall prevention measures. A resident with a history of falls had a scoop mattress without a physician order, while another resident had a scoop mattress despite not being identified as a fall risk. Additionally, a resident with bone density disorders was found without a fall mat alongside her bed, contrary to her care plan. These oversights were identified through observations and staff interviews.
The facility's kitchen failed to meet professional standards for food service safety, with issues including an uncovered ice scoop, a dirty ice machine, unclean kitchen surfaces, and improperly stored food items. The Dietary Manager cited staffing challenges as a barrier to thorough cleaning, while the Administrator acknowledged the need for improved practices to prevent contamination.
The facility failed to ensure call lights were within reach for several residents, risking their ability to obtain assistance. A resident with severe cognitive impairment had her call light clipped out of reach, while another with mobility issues did not know where his call light was. A third resident's call light was attached to a roommate's bedrail, and another's was on the floor under a wheelchair. Staff interviews highlighted the importance of accessible call lights, and the DON and ADON acknowledged the issue, emphasizing staff responsibility to ensure accessibility.
The facility failed to provide proper respiratory care for several residents, leading to potential risks of respiratory infections. A resident's nasal cannula was found unbagged, another's humidifier bottle was empty, and several residents had improperly stored breathing masks. These lapses in equipment storage and maintenance highlight systemic issues in the facility's handling of respiratory care.
Two residents were exposed to potential infection due to improper glove use and hand hygiene by CNAs during incontinence care. One CNA used gloves from her pocket, risking cross-contamination, while another failed to perform hand hygiene between glove changes. Both incidents violated the facility's infection control policies.
A resident's privacy was compromised when RN B assessed and flushed her midline catheter in the hallway instead of in her room, contrary to facility policy. The resident, who was receiving IV antibiotics for a UTI, was observed by the DON, who confirmed that such procedures should be conducted in private to maintain dignity. Interviews with staff reinforced the expectation of conducting treatments in residents' rooms.
A resident with neuromuscular dysfunction of the bladder was using a Purewick system for urinary incontinence, but the Quarterly MDS assessment failed to reflect this. The MDS Nurse admitted the oversight, and the facility's policy requires accurate MDS assessments to reflect the resident's status.
The facility failed to implement comprehensive care plans for two residents, one requiring smoking management and the other needing breathing treatments. A resident with COPD and a history of smoking was not care planned for smoking, while another with acute respiratory failure did not have breathing treatments included in their care plan. Staff acknowledged these oversights, which could impact the residents' care.
A probiotic medication requiring refrigeration was improperly stored on a nurse's cart, contrary to its instructions. LVN A was unaware of the need for refrigeration, which was confirmed during an inspection. Interviews with the facility's administration highlighted a lack of adherence to the medication storage policy, potentially affecting the effectiveness of the probiotics.
A resident with muscle wasting and atrophy was transferred in the hallway instead of her room, breaching privacy. Two CNAs used a Hoyer lift to move her, initially closing the door but then transferring her in the hallway where her wheelchair was located. Interviews with staff highlighted that such transfers should occur in the resident's room to ensure privacy and dignity, as per facility policy.
A resident with severe cognitive impairment and a history of wandering eloped from a secured unit in an LTC facility. The resident was able to exit the facility with the assistance of another resident who knew the door code. The facility's policies for supervision and care planning were not effectively implemented, leading to the incident.
The facility failed to manage beverage containers according to professional standards, as observed during a lunch service. Two beverage containers were not changed out in a timely manner, with labels indicating they were filled the previous day. Staff interviews revealed inconsistencies in practice and a lack of specific policy for managing beverage containers, contributing to the oversight.
An LTC facility failed to report an altercation between two residents to HHSC within the required timeframe. A resident reported being hit by another resident's motorized wheelchair, but the Administrator did not report the incident, considering it an accident. Despite the altercation, both residents felt safe and did not wish to change rooms. The facility's policy mandates immediate reporting of such incidents, which was not followed.
A facility failed to investigate and report an altercation between two residents, where one resident allegedly hit another with a motorized wheelchair. Despite being notified, the Administrator did not report the incident to HHSC or conduct an investigation, as it was initially seen as an accident. The facility's policy requires immediate investigation and reporting of abuse allegations, which was not followed, potentially risking residents' safety.
A resident with Multiple Sclerosis fell from bed and sustained leg fractures, but the incident was not documented or reported to the physician by the attending LVN. The resident was later hospitalized, and the facility's failure to follow protocol delayed medical intervention.
A resident with multiple medical conditions fell from her bed while receiving care, but the incident was not documented or reported by the CNA or LVN involved. The resident was later diagnosed with fractures in her left leg, highlighting a failure in communication and documentation within the facility.
A resident with multiple medical conditions fell from her bed, and the incident was not reported or documented by the staff. The resident's condition worsened, leading to the discovery of fractures days later. The facility's failure to follow protocols for reporting falls and changes in condition resulted in a deficiency, identified as Immediate Jeopardy, due to the risk posed to all residents.
A resident with multiple medical conditions fell out of bed due to inadequate assistance during care. The LVN failed to notify the doctor or document the incident, leading to a delay in medical evaluation. The resident was later diagnosed with fractures in the tibia and fibula.
A resident with Multiple Sclerosis and severe physical impairments was not provided with an updated care plan reflecting her need for a two-person assist, as indicated by her MDS Assessment. Interviews revealed discrepancies between the care plan and assessment, with staff unaware of the inaccuracies. The facility's policy requiring regular review and revision of care plans was not followed.
A facility failed to reposition a resident with a pressure ulcer every two hours as required, leading to the risk of worsening the ulcer. Staff interviews confirmed the resident needed repositioning due to his condition, but this was not done because the staff were busy and the responsibility was not clearly assigned.
Failure to Ensure Accurate Medication Administration and Observation of Ingestion
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications, including failure to follow prescriber orders and to observe residents ingest their medications. One cognitively intact female resident with extensive cardiac, hepatic, hematologic, and psychiatric diagnoses, including a prosthetic heart valve and a care plan identifying risk for bleeding, was ordered Warfarin Sodium 4 mg, two tablets by mouth at bedtime for clotting related to heart failure. Interview and record review showed that on two evenings she was provided a total of four Warfarin tablets instead of the ordered two, after being approached by staff on two separate occasions during the same evening medication pass. The resident reported receiving two Warfarin pills from a certified medication aide (CMA) around one hour after already receiving two Warfarin pills earlier that evening, and on the second night she again received an additional two Warfarin pills after having already taken her ordered dose. The resident stated that on the second night she informed the staff member that she had already received her medications and was not supposed to receive another dose, but the staff member told her they knew what she was supposed to receive and proceeded to give the medication, then walked away without observing ingestion. The resident hid the additional Warfarin tablets under her blanket instead of taking them and later showed them to her roommate, who confirmed that the CMA did not observe either resident swallow their medications. The next morning, the resident gave the two Warfarin tablets to a different CMA, explaining they were extra pills she had not taken. That CMA reported receiving the pills and the explanation from the resident, then passed the pills to the floor RN. The RN acknowledged receiving the returned Warfarin tablets, being informed they were not taken the previous night, and then handing them off to an LVN at shift change without documenting the event, discarding the medication, or following up. Additional interviews revealed a pattern of staff not consistently observing residents take their medications, particularly bedtime medications for sleep. The roommate of the first resident, who was cognitively intact and required staff assistance with several ADLs, reported that she was given Melatonin 3 mg at bedtime but that the CMA did not watch her take it; she held onto the pill until she was ready to sleep and stated that staff did not always observe her or her roommate taking medications. A cognitively intact male resident with insomnia and multiple comorbidities, including COPD and CNS disorder, reported that staff did not always observe him take his Zolpidem Tartrate 5 mg; he stated that staff often gave his sleep medication early in the evening and he would hold onto it until he was ready for sleep, sometimes calling staff over later to show he had taken it. The DON and Administrator stated they were not aware of the Warfarin medication errors and confirmed that the expectation and facility policy were that nurses and CMAs must monitor residents while taking medications, never walk away without observing ingestion, and that any medication returned by a resident should be discarded, documented, and reported. Facility policies on administering medications and on adverse consequences and medication errors required medications to be administered as prescribed, inappropriate or excessive doses to be addressed with the prescriber, and medication errors to be documented and monitored, which did not occur in these instances. Further interviews with staff involved in the Warfarin administration showed additional failures in medication control and documentation. The CMA who worked weekend double shifts acknowledged administering Warfarin to the resident twice in the evening on at least one day, totaling four pills, stating she gave what appeared in the electronic system and that both med aides and nurses were responsible for administering blood thinners. She stated she believed she observed the resident take the medications and was unaware the resident had not taken the extra pills. The LVN who received the returned Warfarin from the RN identified the pills as Warfarin, determined they could only belong to the resident on Warfarin, and learned from the resident that she had received an additional dose after already taking two pills. The LVN reported finding two packs of Warfarin on the med aide cart in addition to packs on the nurse’s cart, removed the extra packs from the med aide cart, and discarded the returned pills without documenting the incident or reporting it to the DON. These actions and inactions, including duplicate Warfarin availability on multiple carts, failure to follow physician orders, failure to observe medication ingestion, and failure to document and report medication errors, led to the cited deficiency in pharmaceutical services.
Failure to Implement Enhanced Barrier Precautions During Wound and Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its Enhanced Barrier Precautions (EBP) infection control program for residents with pressure ulcers. Resident #1, an older female with severe cognitive impairment (BIMS score of 0) and pressure ulcers on the sacral region and medial lateral foot, had a care plan requiring staff to wear gowns and gloves during high-contact care activities under EBP. A sign was posted on her door indicating EBP and the requirement for gown and gloves with all direct care. However, there was no PPE available outside her room at the time of observation. On the observed date and time, RN A and CNA B provided incontinence care to Resident #1 while only wearing gloves and not donning gowns, despite the EBP signage and care plan requirements. Later, RN A performed wound care on Resident #1’s sacral and foot pressure ulcers, again wearing only gloves and not a gown. RN A followed hand hygiene and glove changes between steps but did not use a gown at any point during the wound care. In interviews, CNA B stated she knew she was supposed to wear PPE when an EBP sign was present and that staff should wear gowns and gloves when caring for residents with wounds, but she reported she did not recall seeing the sign and that there was no PPE cart at the door. RN A acknowledged she was aware of the requirement to wear a gown and gloves for Resident #1 under EBP, stated she forgot because she was anxious and there was no PPE bin by the door, and confirmed that failure to use EBP could lead to cross contamination. Resident #2, an older female with moderate cognitive impairment (BIMS score of 10) and pressure ulcers on the sacral region and left ankle, also had a care plan requiring EBP with staff wearing gowns and gloves during high-contact care activities. During observation, LVN C performed wound care on Resident #2’s sacral and ankle pressure ulcers, including removal of old dressings with drainage, cleansing of the wounds, and application of collagen powder, calcium alginate, and dry dressings, while only wearing gloves and not a gown. In an interview, LVN C stated she forgot to wear PPE because she was nervous, noted that PPE had previously been placed in bins by residents’ doors but was not present that day, and acknowledged awareness of the requirement to wear a gown and gloves for Resident #2 under EBP and that failure to use EBP could result in cross contamination. The DON stated staff were required to wear gowns and gloves for direct contact with residents on EBP, such as turning, incontinence care, and wound care, and that EBP were in place to protect residents from exposure to infectious agents on providers’ clothing. Training records showed that RN A, CNA B, and LVN C had not attended the facility’s EBP training.
Failure to Conceal Catheter Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not concealing her catheter bag from public view. During observations, the resident's catheter bag was seen hanging from her bed without a privacy bag, making it visible from the hallway. Interviews with an LVN and the DON confirmed that the resident should have had a privacy bag to maintain her dignity, and that it was standard practice for nursing staff to ensure all residents with catheter bags had privacy bags in place. The resident involved was a female with neuromuscular dysfunction of the bladder, an active urinary tract infection, and a physician's order for a Foley catheter. The facility's own policy on dignity emphasized care that promotes residents' well-being and self-worth. Despite this, the catheter bag was left uncovered and visible, contrary to both facility policy and staff expectations, resulting in a failure to maintain the resident's right to a dignified existence.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to three residents who required assistance, as observed during a survey. For one resident with a history of stroke, muscle weakness, and total dependence on staff for activities of daily living, the call light was found on the floor near the nightstand, out of reach while the resident was lying in bed. A registered nurse confirmed uncertainty about the resident's ability to use the call light and acknowledged that staff should ensure call lights are within reach during rounds. Another resident with severe cognitive impairment and reduced mobility was observed with the call light under the bed and out of reach, despite care plan interventions specifying the need for the call light to be accessible and for staff to encourage its use. A third resident, who had a displaced fracture, reduced mobility, and was a fall risk, was found with the call light hanging off a side rail and nearly touching the floor, also out of reach. The resident was unaware of the call light's location. Interviews with nursing staff, including an LVN and the DON, revealed that staff often forgot to return the call light to an accessible position after providing care, and that this oversight could prevent residents from calling for help. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not consistently followed for the residents observed.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents requiring such care, as evidenced by improper storage of respiratory equipment for two residents. For one resident with COPD and respiratory failure, observations revealed that her nasal cannula was left hanging unbagged from her wheelchair and her CPAP mask was placed unbagged on her nightstand, despite not being in use. The resident confirmed she had not used the oxygen or CPAP since the previous night or earlier that morning. A registered nurse acknowledged that respiratory devices should be bagged when not in use to prevent infection and stated it was the nurses' responsibility to ensure this was done. Another resident with chronic respiratory failure was observed with her nasal cannula on the floor, hanging from her wheelchair and unbagged when not in use. A licensed vocational nurse confirmed that the devices needed to be bagged to avoid infection and that it was the nurses' responsibility to check for this. The Director of Nursing also stated that respiratory devices should be bagged when not in use and that she and the nurses check for this throughout the day. Review of the facility's policy on oxygen administration indicated the need to follow physician's orders and ensure safe handling of respiratory equipment.
Inadequate Supervision and Improper Transfer Technique Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) attempted to transfer a resident who required a two-person assist with a Hoyer lift, using a sliding board and without assistance from another staff member. The resident, who had a history of Parkinson's disease, prior stroke with left-sided deficits, non-Alzheimer's dementia, hemiplegia, and was on blood thinners for atrial fibrillation, was care planned for two-person Hoyer lift transfers due to her high risk for injury and fear of falling. Despite these documented needs, the CNA proceeded with a one-person sliding board transfer, for which she was not trained or delegated, and did not request help from another staff member. During the transfer, the CNA left the resident unattended while preparing the bed, at which point the resident attempted to scoot forward onto the sliding board from her wheelchair. The resident lost balance, fell to the floor, and struck her head. The incident was witnessed by another CNA who heard the fall and immediately notified the charge nurse. Upon assessment, the resident was found to have a hematoma on the left side of her head, bruising to both hands, and was subsequently sent to the hospital where a CT scan revealed a subarachnoid hemorrhage in the left temporal lobe. Interviews with staff and review of facility policies confirmed that nursing staff were not permitted to use sliding boards for this resident, and that at least two staff were required for mechanical lift transfers. The CNA involved admitted to not being trained for sliding board transfers for this resident and acknowledged that the resident was normally a two-person assist. The therapy department had been working with the resident on sliding board transfers, but only therapy staff were authorized and trained to perform them. The facility did not provide a specific transfer policy when requested.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in 9 of 12 rooms reviewed. Observations revealed that air vents in these rooms were covered with thick black and brown dirt, and bathroom sink faucets had thick white stains. Additionally, soap dispensers had reddish stains, and some rooms had large holes in the walls or debris behind beds. Mini fridges in certain rooms contained brown and red stains, indicating a lack of thorough cleaning and sanitation. Interviews with housekeeping staff and the supervisor highlighted a lack of clarity and responsibility regarding cleaning duties. Housekeepers acknowledged their responsibility for cleaning various areas, including vents, windows, and bathrooms, but there was confusion about who was responsible for cleaning mini fridges. The housekeeping supervisor admitted to not knowing who should clean the mini fridges and stated that leadership was supposed to check for cleanliness issues during morning rounds. The facility's administrator recognized that housekeeping was not performing thorough cleaning, and the housekeeping supervisor was not adequately checking their work. Leadership was also not ensuring room cleanliness during daily rounds. The administrator noted that these deficiencies could impact infection control, as the facility's policy emphasized providing a clean, sanitary, and homelike environment for residents.
Failure to Ensure Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents. Resident #17, a female with a history of falls and moderate cognitive impairment, was observed with a scoop mattress on her bed without a corresponding physician order, despite her care plan indicating the need for such a mattress. Similarly, Resident #26, a male with a history of stroke and an amputation, was also found with a scoop mattress on his bed without a physician order, although his care plan did not identify him as a fall risk. Resident #34, a female with a history of falls and bone density disorders, was observed without a fall mat alongside her bed, contrary to her care plan's intervention for fall prevention. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the absence of the fall mat was due to oversight after the resident's return from the hospital. The facility's policy on fall prevention requires that each resident be assessed for fall risk and receive care according to their individualized risk level, which was not adhered to in these cases.
Deficiencies in Kitchen Sanitation and Food Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. The ice scoop for the ice machine was not properly covered, exposing it to air-borne contaminants, and the ice machine itself had a dirty filter and stained interior walls. The kitchen floor and walls were not adequately cleaned, with dirt and dried stains present. Additionally, kitchen equipment, including a microwave and a table with drink dispensers, had visible stains, and containers of flour and sugar were not clean. Food storage practices were also deficient, with items in the refrigerator and freezer not being properly labeled, dated, or sealed, increasing the risk of contamination. Interviews with the Dietary Manager and Administrator revealed that the facility had a cleaning schedule, but staffing challenges hindered thorough cleaning efforts. The Dietary Manager acknowledged the issues, noting that the kitchen and equipment were cleaned monthly, but staff often hurried and neglected to seal food items properly. The Administrator recognized the need for improved cleaning and food storage practices to prevent potential infections. The facility's policy on kitchen sanitation emphasized the importance of routine cleaning and proper food storage, aligning with FDA guidelines to protect food from contamination.
Failure to Ensure Call Lights Are Accessible to Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for five residents, which could place them at risk of being unable to obtain assistance when needed. Resident #58, a female with severe cognitive impairment and a history of falls, was observed with her call light clipped to the light over her bed, out of reach. Similarly, Resident #56, a male with moderate cognitive impairment and mobility issues, did not know where his call light was, as it was attached to the bedrail of an unoccupied bed. Resident #54, a female with severe cognitive impairment and muscle wasting, had her call light attached to her roommate's bedrail, making it inaccessible. Resident #61, a female with severe cognitive impairment and a history of falls, had her call light on the floor under her wheelchair, which was not easily reachable. Resident #120, a male with moderate cognitive impairment and extensive assistance needs, had his call light on the floor, out of reach, until a CNA picked it up and clipped it to his bed. Interviews with staff, including CNAs and LVNs, highlighted the importance of having call lights within reach to alert staff for assistance, especially in emergencies. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged the issue, noting that residents might not know how to use the call light or might disconnect it. They emphasized the responsibility of all staff to ensure call lights are within reach, as residents might not receive help when needed if they cannot access their call lights. The facility's policy on answering call lights, revised in March 2021, stated that call lights should be within easy reach when residents are in bed or confined to a chair.
Improper Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide proper respiratory care for several residents, leading to potential risks of respiratory infections and unmet respiratory needs. Resident #120's nasal cannula was observed hanging unbagged on the oxygen concentrator, which could lead to contamination and infection. The resident, a male with heart failure and respiratory failure, had a care plan that included oxygen therapy, but the lack of proper storage for the nasal cannula was a significant oversight. Resident #10, a female diagnosed with respiratory failure, was found using an oxygen concentrator with an empty humidifier bottle. Despite having a care plan that required monitoring and refilling the humidifier bottle every shift, the resident reported dryness in her nose, indicating the humidifier had not been maintained as required. This neglect in maintaining the humidifier bottle could lead to nasal irritation and discomfort for the resident. Other residents, including Resident #11, #49, and #32, also experienced similar issues with their respiratory equipment. Resident #11's breathing mask was not stored properly, and Resident #49's nasal cannula and breathing mask were found unbagged, with the nasal cannula even on the floor. Resident #32's breathing mask was left unbagged on her side table. These lapses in proper storage and maintenance of respiratory equipment highlight a systemic issue in the facility's handling of respiratory care, potentially exposing residents to cross-contamination and infection.
Infection Control Deficiencies in Glove Use and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by two separate incidents involving improper glove use and hand hygiene during incontinence care. In the first incident, a CNA was observed using gloves taken from the pocket of her scrub top while providing care to a resident. This resident, who had severely impaired cognition and required extensive assistance with toileting, was at risk for cross-contamination due to the CNA's actions. The CNA admitted to storing gloves in her pocket because the facility did not provide gloves in the resident's room, acknowledging the risk of cross-contamination. In the second incident, another CNA failed to perform hand hygiene between glove changes while providing incontinence care to a different resident. This resident, diagnosed with Alzheimer's disease and requiring extensive assistance with toileting, was exposed to potential infection due to the CNA's failure to use hand sanitizer or wash her hands after removing soiled gloves. The CNA acknowledged the importance of hand hygiene and admitted to not following the facility's training on proper handwashing procedures. Both incidents highlight a lapse in adherence to the facility's hand hygiene policy, which mandates handwashing or the use of hand sanitizer before donning and after doffing gloves. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the actions of the CNAs constituted cross-contamination and increased the risk of infection for the residents involved.
Failure to Maintain Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to maintain the privacy and dignity of a resident during a medical procedure. On the specified date, RN B assessed and flushed a midline catheter for a resident in the hallway instead of inside the resident's room. This action was observed by the Director of Nursing (DON), who noted that the procedure should have been conducted in private to ensure the resident's dignity and privacy were maintained. The resident, who had a urinary tract infection and was receiving intravenous antibiotics, was in the hallway with RN B when the procedure was performed. Interviews with the DON, RN B, the Administrator, and the Assistant Director of Nursing (ADON) confirmed that the expectation was for all medical treatments to be conducted in the privacy of the resident's room. The facility's policy on dignity and privacy was not adhered to, as the procedure was performed in a public area, potentially exposing the resident's medical condition to others. The resident expressed that while she did not mind the procedure being done in the hallway, she acknowledged that it should have been done in her room if that was the requirement.
Inaccurate MDS Assessment for External Catheter Use
Penalty
Summary
The facility failed to ensure that a resident's Quarterly MDS assessment accurately reflected the use of an external catheter, specifically a Purewick system, which is a non-invasive urinary drainage device. The resident, a cognitively intact female with a diagnosis of neuromuscular dysfunction of the bladder, was frequently incontinent and used the Purewick system while in bed. Despite this, the MDS assessment did not indicate the use of an external catheter, which was an oversight by the MDS Nurse. The resident's care plan and physician orders did reflect the use of the Purewick system, and staff interviews confirmed its use and monitoring. The Director of Nursing (DON) was not familiar with the MDS process, and the MDS Nurse acknowledged the oversight, stating that the MDS should have included the use of the Purewick system. The MDS Nurse admitted that the omission was an error and planned to audit the MDS assessments to ensure accuracy. The facility's policy requires that the MDS assessment accurately reflects the resident's status during the observation period, and the Resident Assessment Coordinator is responsible for ensuring the completion of the MDS for each resident.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which could potentially impact the care they receive. Resident #50, a female with a history of heart failure, absence of both legs below the knees, and chronic obstructive pulmonary disease, was identified as a smoker. However, her care plan did not include any provisions for her smoking habits, despite being listed as a smoker in the facility's records. The Social Worker, responsible for completing smoking assessments, acknowledged the oversight and the potential impact on the resident's care. Resident #11, a male with acute respiratory failure and severe cognitive impairment, required breathing treatments as per his physician's orders. However, his care plan did not reflect this need, which was confirmed during an observation of a Licensed Vocational Nurse administering the treatment. The Assistant Director of Nursing and the Director of Nursing both recognized the importance of having a comprehensive care plan to ensure all staff are aware of the necessary interventions for each resident. Interviews with facility staff, including the MDS Nurse and the Administrator, highlighted the expectation that all residents should have detailed and individualized care plans. The absence of such plans for these residents was acknowledged as an oversight, with staff admitting the potential for confusion and inadequate care provision without proper documentation in the care plans.
Improper Storage of Probiotic Medication
Penalty
Summary
The facility failed to ensure proper storage of a probiotic medication, which was observed on a nurse's cart with instructions to refrigerate after opening. LVN A, who was responsible for the cart, was unaware that some probiotics required refrigeration to maintain their effectiveness. During an inspection, LVN A acknowledged the oversight and indicated she would inform the Director of Nursing (DON) about the issue. Interviews with the facility's administration, including the Administrator, Assistant Director of Nursing (ADON), and DON, revealed a lack of awareness and adherence to the facility's medication storage policy. The Administrator and ADON both recognized the importance of refrigerating certain probiotics to ensure their effectiveness. The DON confirmed that the expectation was for staff to be vigilant about storing medications and supplements that required refrigeration, and acknowledged that the failure to refrigerate the probiotics could render them ineffective.
Privacy Breach During Resident Transfer
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during a transfer procedure. The resident, a cognitively intact female with muscle wasting and atrophy, required extensive assistance from two staff members for transfers using a mechanical lift. On the day of the incident, two CNAs were observed transferring the resident from her bed to a wheelchair. Although the CNAs initially closed the door while raising the resident with the Hoyer lift, they proceeded to transfer her in the hallway, where her wheelchair was located, rather than inside her room. Interviews with the CNAs, ADON, DON, and the Administrator revealed that the transfer should have been conducted inside the resident's room to ensure privacy and dignity. The CNAs acknowledged the potential dignity issue, and the ADON and DON emphasized that all care should be provided in the privacy of the resident's room, regardless of the resident's expressed indifference. The facility's policy on dignity and privacy was not adhered to during this incident, as the transfer in the hallway exposed the resident to potential embarrassment.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in the elopement of a resident from the secured care unit. The resident, who had a history of severe cognitive impairment and wandering behavior, was able to exit the facility and was found sitting outside on a bench. The resident's comprehensive care plan identified her as at risk for wandering and elopement, necessitating her residence in the secured unit. On the day of the incident, a staff member observed the resident outside and redirected her back inside. It was determined that another resident, who was cognitively intact and had access to the facility's front door code, facilitated the elopement by opening the door for the resident. The facility's doors were alarmed with codes that only staff were supposed to have access to, but the resident who assisted in the elopement was aware of the code. Interviews with staff and the facility's administration revealed that the resident was able to exit the secured unit, although the exact method was unclear. The facility's administrator and DON confirmed that the doors were functioning properly and that the codes had been changed following the incident. The facility's policy required adequate supervision and a person-centered care plan to prevent such incidents, but these measures were not effectively implemented, leading to the resident's elopement.
Failure to Properly Manage Beverage Containers
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. During an observation of the lunch dining service, two beverage containers were found in the dining area with labels indicating they were filled the previous day. The staff member responsible for these containers admitted to not changing out the beverages in a timely manner due to a busy morning, which is against the facility's expectations for daily cleaning and changing of beverage containers. Interviews with various staff members, including the Dietary Manager (DM), Assistant Director of Nursing/Infection Control Preventionist (ADON/ICP), Director of Nursing (DON), and the facility's Administrator, revealed a lack of consistent practice and policy regarding the cleaning, labeling, and changing of beverage containers. The facility did not have a specific policy for beverage container management, which contributed to the oversight. The U.S. Food Code requires that ready-to-eat, time/temperature control for safety (TCS) food be marked with a date or day for consumption or disposal, which was not adhered to in this instance.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an alleged altercation between two residents to the Health and Human Services Commission (HHSC) within the required timeframe. The incident involved a resident who reported being hit on the leg by another resident's motorized wheelchair. The altercation was reported to the facility's Assistant Director of Nursing (ADON) and subsequently to the Director of Nursing (DON) and the Administrator. However, the Administrator did not report the incident to HHSC, as it was perceived as an accident rather than an intentional act of abuse. Resident #2, who was cognitively intact, reported that Resident #3 deliberately hit him with a motorized wheelchair. Resident #3, who had moderate cognitive impairment, admitted to bumping into Resident #2 but denied any intentional harm. The ADON intervened promptly during the incident and separated the residents. Despite the altercation, both residents expressed feeling safe at the facility and did not wish to change rooms or facilities. The facility's policy requires immediate reporting of any alleged abuse, neglect, or mistreatment to the Administrator and state agency. The Administrator acknowledged the responsibility to report such incidents but failed to do so, as the event was not initially considered abuse. This oversight could potentially place residents at risk of continued abuse and injuries of unknown origins, affecting their emotional and physical well-being.
Failure to Investigate and Report Resident Altercation
Penalty
Summary
The facility failed to thoroughly investigate and report an alleged altercation between two residents, as required by state law. The incident occurred when one resident, who uses a motorized wheelchair, allegedly hit another resident's leg while trying to pass in a common area. The resident who was hit reported feeling safe overall but described the other resident as a bully. The facility's Assistant Director of Nursing (ADON) intervened during the incident and reported it to the facility's Abuse Coordinator and Administrator. Despite being notified of the incident, the Administrator did not report it to the Health and Human Services Commission (HHSC) or conduct an investigation, as it was initially presented as an accident. The Director of Nursing (DON) stated that it was the Administrator's responsibility to report and investigate any allegations of abuse or neglect. The facility's policy requires immediate investigation and reporting of any suspected abuse, but this protocol was not followed in this case. The failure to investigate and report the incident within the required timeline could place residents at risk of continued abuse and injuries of unknown origins. The facility's policy emphasizes the importance of protecting residents' health, welfare, and rights by promptly addressing any allegations of abuse. The Administrator acknowledged the importance of reporting and investigating such incidents to prevent ongoing abuse.
Failure to Notify Physician and Document Resident Fall
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify relevant parties following an accident involving the resident, which resulted in injury and had the potential for requiring physician intervention. The incident involved a resident with multiple medical conditions, including Multiple Sclerosis, who was nonverbal and dependent on staff for all activities of daily living. On the evening of the incident, a CNA was providing incontinent care when the resident rolled off the bed onto a floor mat. The CNA then sought assistance from an LVN, who helped return the resident to bed without documenting the incident or notifying the physician or family. The resident was later diagnosed with fractures in the tibia and fibula of the left leg after being sent to the hospital several days following the fall. The LVN did not report the fall or complete an incident report, and the resident's physician was not informed until several days later. The lack of immediate notification and documentation of the fall delayed the resident's assessment and treatment, potentially exacerbating the injury. Interviews with facility staff revealed that the LVN and CNA did not follow the facility's protocol for reporting falls and changes in condition. The LVN admitted to forgetting to document the incident due to being busy with other residents. The facility's Director of Nursing and Administrator were unaware of the fall until several days later, prompting an investigation and subsequent staff training on proper notification procedures.
Neglect and Documentation Failure Leads to Resident Injury
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a fall that was not properly documented or reported. The incident involved a resident with multiple medical conditions, including multiple sclerosis, who was dependent on staff for all activities of daily living. On the day of the incident, a CNA was providing incontinent care when the resident fell from the bed onto a floor mat. The CNA did not report the fall to the Director of Nursing (DON) or the Administrator, and the Licensed Vocational Nurse (LVN) who assessed the resident also failed to document the incident or notify the resident's doctor. The resident was later sent to the hospital, where she was diagnosed with fractures in her left tibia and fibula. The facility's records did not initially reflect any fall or incident, and the resident's care plan did not indicate any changes in her condition. Interviews with staff revealed that the CNA and LVN did not follow proper procedures for reporting and documenting the fall, and the resident's condition was not adequately monitored following the incident. The lack of documentation and communication led to a delay in identifying the resident's injuries, which were only discovered after the resident was transferred to the hospital. The facility's failure to report and document the fall, as well as the lack of immediate medical assessment, constituted neglect and placed the resident at risk of further harm.
Failure to Report and Document Resident Fall
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent neglect, resulting in a deficiency related to the care of a resident. The resident, who had multiple medical conditions including Multiple Sclerosis and was nonverbal, experienced a fall on August 2, 2024, which was not properly reported or documented by the staff involved. CNA A was providing incontinent care when the resident rolled off the bed onto a floor mat. Despite the fall, no immediate injuries were noted, and the resident was assisted back into bed by CNA A and LVN B. However, the incident was not reported to the Director of Nursing (DON) or the Administrator, and no x-rays were conducted at that time. The resident's condition worsened over the following days, with swelling and discoloration observed in her left leg. It was not until August 8, 2024, that an x-ray revealed fractures in the resident's tibia and fibula, leading to her transfer to the hospital. The lack of documentation and notification of the fall delayed appropriate medical intervention and assessment, which could have mitigated the resident's injuries. Interviews with staff revealed a lack of understanding and adherence to the facility's protocols for reporting falls and changes in resident conditions. The deficiency was identified as Immediate Jeopardy on August 11, 2024, due to the potential risk to all residents from the failure to assess and treat incidents in a timely manner. The facility's neglect in following its own policies and procedures for reporting and responding to falls and injuries placed residents at risk of harm, highlighting significant gaps in communication and training among the staff.
Failure to Provide Appropriate Care and Incident Reporting
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one resident. A Certified Nursing Assistant (CNA) did not provide incontinent care with a second staff member assisting, which resulted in the resident falling out of bed. The Licensed Vocational Nurse (LVN) failed to notify the resident's doctor after the incident, did not complete and document a head-to-toe assessment, and did not monitor the resident or perform neuro checks. Consequently, the resident was sent to the hospital several days later and was diagnosed with fractures in the tibia and fibula of the left lower leg. The resident involved was a female with multiple medical conditions, including Multiple Sclerosis, hypertension, and cardiac arrhythmia, among others. She was nonverbal, bed-bound, and required total assistance for activities of daily living (ADLs). The resident's care plan indicated that she was at risk for falls and required a fall prevention program. Despite these needs, the incident was not documented in the resident's progress notes, and no immediate medical evaluation was conducted following the fall. Interviews with staff revealed that the CNA and LVN did not follow proper procedures for reporting and documenting the fall. The CNA stated that the resident rolled off the bed during care, and the LVN admitted to not notifying the doctor or completing an incident report. The Director of Nursing (DON) and other staff were unaware of the fall until several days later, leading to a delay in the resident receiving appropriate medical attention. The facility's failure to adhere to established protocols for incident reporting and resident care resulted in a deficiency being identified by surveyors.
Failure to Update Care Plan for Resident with Multiple Sclerosis
Penalty
Summary
The facility failed to review and revise the care plan for a resident after her Minimum Data Set (MDS) Assessment indicated she required a two-person assist for bed mobility and incontinent care. The resident, who was admitted with multiple health issues including Multiple Sclerosis, was assessed as having moderate impaired cognition, severe memory problems, and significant physical impairments. Despite these findings, the care plan was not updated to reflect the resident's current needs, which could lead to unmet needs and potential health risks. Interviews with facility staff revealed discrepancies between the MDS Assessment and the care plan. The Director of Nursing (DON) and the MDS Coordinator acknowledged that the care plan should match the MDS Assessment, but the resident's care plan inaccurately indicated a one-person assist for bed mobility and hygiene. The MDS Coordinator admitted that the resident's status varied due to muscle spasms, and the care plan should have been updated to reflect a two-person assist requirement. Further interviews highlighted a lack of awareness among staff regarding the inaccuracies in the care plan. The Medical Director confirmed the resident's need for total assistance due to her condition. The DON and the facility Administrator were unaware of the care plan discrepancies, indicating a breakdown in communication and oversight. The facility's policy mandates that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Failure to Reposition Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless unavoidable. Specifically, the facility did not reposition a resident with a pressure ulcer on his sacrum every two hours as required. Observations on the day of the survey showed the resident lying on his back for extended periods without being repositioned. Interviews with staff, including a CNA, an LVN, and the DON, confirmed that the resident needed to be repositioned every two hours due to his condition, but this was not done because the staff were busy and the responsibility was not clearly assigned. The resident in question was a [AGE] year-old male with a diagnosis that included a pressure ulcer on the sacrum, hemiplegia, and tracheostomy status. His care plan specifically required repositioning every two hours to prevent further skin breakdown. Despite this, the resident was observed lying on his back for over four hours without being repositioned. Staff interviews revealed a lack of clarity and execution in the responsibility for repositioning the resident, leading to a failure in providing the necessary care to prevent the worsening of the pressure ulcer. The facility did not provide a policy on repositioning at the time of the survey exit.
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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