Grace Pointe Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 2301 N Oregon St, El Paso, Texas 79902
- CMS Provider Number
- 675106
- Inspections on file
- 36
- Latest survey
- December 31, 2025
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Grace Pointe Wellness Center during CMS and state inspections, most recent first.
A resident with a history of lupus and intact cognition experienced inconsistencies in the administration and documentation of Acetaminophen with Codeine for pain management. Although physician orders allowed for 2 tablets as needed, records showed only 1 tablet was dispensed at times, and documentation on the EMAR and Narcotic Count Sheet did not match. Nursing staff interviews confirmed required procedures for medication checks and documentation were not consistently followed, resulting in inaccurate records.
A facility with 154 beds did not employ a qualified full-time social worker after the previous social worker resigned, and a replacement only worked for about a week before also resigning. The Administrator confirmed that no interim support was sought from other company facilities, resulting in a gap in social services coverage for residents' psychosocial and discharge planning needs.
A resident with multiple medical conditions filed grievances related to maintenance and activities, but the facility failed to document resolutions or provide written decisions as required. Staff interviews and record reviews revealed incomplete grievance forms and a lack of follow-through, with several grievances over multiple months lacking evidence of resolution or communication to the resident.
The facility did not complete the required annual Employee Misconduct Registry and Nurse Aide Registry screenings for an LVN, as mandated by its abuse prevention policies. This oversight resulted in a lapse in the implementation of procedures designed to prohibit and prevent abuse, neglect, and exploitation.
A facility failed to send a required discharge notice to the local Ombudsman when a resident was issued a facility-initiated discharge for non-payment of a private room. Although the discharge notice stated that a copy had been sent, interviews and record review confirmed that the Ombudsman did not receive the notice as required. The resident had multiple medical conditions and required 24-hour nursing care.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
A resident with moderate cognitive impairment and significant physical disabilities reported sexual abuse by a CNA during personal care. Despite the disclosure to multiple staff members, the allegation was not investigated, the alleged perpetrator was not suspended, and the incident was not reported to law enforcement or the State Agency as required. The only action taken was to restrict male staff from caring for the resident, with no documentation or escalation to the Administrator, resulting in a serious breakdown of abuse prevention protocols.
A resident with moderate cognitive impairment reported to staff that a CNA had sexually abused him during a shower, but the allegation was not immediately reported to the administrator or law enforcement as required. Staff communicated the allegation among themselves, but confusion over reporting responsibilities led to a lack of documentation and delayed action. The accused CNA continued working until the incident was discovered by surveyors, revealing a breakdown in the facility's abuse reporting protocol.
A resident with vascular dementia and moderate cognitive impairment alleged inappropriate sexual contact by a CNA during bathing. The incident was not promptly or properly reported, documented, or investigated, and the alleged perpetrator continued working in the facility with access to other residents. Staff interviews revealed confusion and inconsistent adherence to abuse reporting protocols, and required documentation and administrative notification were lacking.
A resident with moderate cognitive impairment and a history of vascular dementia, hemiplegia, and hemiparesis had a documented preference for no male CNAs in their room following an allegation of sexual abuse. This preference, noted in a social services assessment, was not included in the resident's care plan, and staff were inconsistently aware of the instruction. The facility failed to document or communicate the resident's preference, resulting in a lack of a comprehensive, person-centered care plan.
A resident with moderate cognitive impairment and multiple medical conditions reported being inappropriately touched by a CNA during a shower. Although the allegation was communicated among staff, there was no documentation of the incident in the resident's medical record or facility reports, contrary to facility policy and accepted standards.
The facility failed to provide residents with reasonable access to a telephone and a private place to make calls without being overheard. A resident was observed using a phone at the nurses' station, compromising privacy. The chapel phone, intended for private use, was non-functional due to construction. Staff and residents confirmed the lack of privacy, with some residents feeling embarrassed. The facility's policy on resident rights to privacy was not followed, and some staff were unaware of the need for privacy during phone calls.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident with diabetes and peripheral vascular disease was not seen by a podiatrist, resulting in long, yellow, and chipped toenails. Another resident with severe cognitive impairment and dementia exhibited wandering behavior that was not addressed in her care plan. The facility's lack of proper documentation, communication, and follow-up contributed to these deficiencies.
Two residents in the facility did not receive proper foot care, leading to deficiencies in maintaining their foot health. One resident with diabetes and peripheral vascular disease had overgrown and discolored toenails due to a lack of timely podiatry services. Another resident with severe cognitive impairment also had long, thick, and discolored toenails, with no recent podiatrist visit. The facility's policy required regular foot assessments and podiatrist referrals, but there was a breakdown in communication and documentation, resulting in inadequate care.
The facility failed to maintain clean oxygen concentrator filters for two residents, both with respiratory conditions, by not adhering to weekly cleaning protocols. The filters were found dirty, and the orders for cleaning had been discontinued without proper documentation. Staff interviews revealed a lack of clear responsibility for maintaining the filters, contrary to facility policy and manufacturer guidelines.
The facility failed to ensure proper pharmaceutical services, including accurate reconciliation of controlled substances, proper medication storage, and updating medication labels following physician order changes. Observations revealed issues such as incomplete documentation of controlled substance counts, improper storage of liquid medications, and failure to update medication labels, posing risks of drug diversion and incorrect medication administration.
The facility did not refrigerate an opened bottle of Acidophilus Probiotic Dietary Supplement as required, found on a Medication Aide's cart. LVN B confirmed the manufacturer's label instructed refrigeration after opening and removed the bottle. This oversight could impact medication efficacy and availability.
The facility failed to maintain proper food storage and sanitation procedures, as observed during a survey. Foods were not stored in sealed containers, and the kitchen had maintenance issues such as missing ceiling tiles and lint-covered vents. The Three-Compartment Sink Procedures were not followed, with staff not immersing items in sanitizer for the required time. The facility's dietary services policy, which outlined proper food storage and equipment sanitation, was not adhered to, potentially risking foodborne illnesses.
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene practices during meal service and inadequate storage of medical supplies and personal belongings. An LVN did not perform hand hygiene after repositioning a resident, and open medical supplies were found on a treatment cart. Personal items were stored on a clean linen table shelf, contrary to facility policy, increasing the risk of cross-contamination.
The facility failed to maintain a safe and functional environment, as several resident rooms had closet doors off their tracks, lacking necessary guides, posing potential injury risks. Observations and interviews revealed a lack of communication and awareness among staff, with the Maintenance Supervisor confirming the hazard. The facility's policy emphasizes a safe environment, yet the current state of the closet doors indicates a deficiency.
A resident with severe cognitive and physical impairments was found without a reachable call light, contrary to their care plan. Staff interviews revealed a lack of communication and adherence to the care plan, as the resident could not use a regular call light due to hand contractures. The facility lacked a call light policy, contributing to the deficiency.
A resident reported that a nurse entered his room without permission while he was naked, leading to feelings of embarrassment and a loss of dignity. The facility's policy requires staff to knock and wait for permission before entering, but the grievance remained unresolved.
A resident received an opened letter from a family member, violating their right to privacy. The Business Office staff admitted to routinely opening mail unless residents were on a specific list. Despite a policy to deliver unopened mail, the facility failed to consistently follow this protocol, leading to a grievance filed by the resident.
The facility failed to prevent abuse when a resident verbally threatened another resident in the morning, which was not reported or investigated. Later that day, the same resident physically assaulted the other in the dining room. Both residents have histories of aggressive behavior and cognitive impairments, but the facility did not adequately monitor or protect them, leading to the altercation.
The facility failed to implement policies to prevent abuse, neglect, and exploitation, leading to a physical altercation between two residents. An earlier verbal threat was not reported or investigated, and both residents' care plans were not effectively followed, resulting in inadequate protection and monitoring.
The facility failed to report an altercation between two residents, where one resident physically assaulted another. The incident was not reported to the Administrator, putting residents at risk of injury. Both residents had histories of aggressive behavior and cognitive impairments, but the facility did not follow its abuse prevention and reporting protocols.
A resident with dementia exhibited ongoing wandering behaviors that were not adequately tracked or addressed by the facility. Despite being identified as at risk for wandering, the resident's care plan lacked specific interventions, placing him at risk of harm. Medical records and staff interviews revealed inconsistent monitoring and a lack of proper assessment of the resident's behaviors.
Failure to Accurately Document and Administer Controlled Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for one resident. Specifically, there was a discrepancy between the physician's orders for Acetaminophen with Codeine and the documentation on the resident's Electronic Medication Administration Record (EMAR) and Narcotic Count Sheet. The physician's orders were updated to allow for 2 tablets every 6 hours as needed for pain, but the Narcotic Count Sheet indicated that only 1 tablet was pulled and administered on several occasions, while the EMAR reflected administration of 2 tablets. Interviews with staff confirmed that only nurses were to administer and document narcotic medications, and that procedures required immediate and accurate documentation on both the EMAR and Narcotic Count Sheet. However, inconsistencies in documentation and administration were identified, with staff unable to explain the discrepancies. The resident involved had a history of Systemic Lupus Erythematosus and was cognitively intact, with a care plan addressing the need for pain management. The resident reported receiving 1-2 tablets at different times and was unaware of the reason for the variation. Staff interviews revealed that nurses were trained to perform medication checks and document administration, but there was uncertainty regarding the monitoring frequency of narcotic counts by the DON. Facility policy required immediate documentation of controlled medication administration, but this was not consistently followed, leading to inaccurate records for the resident's pain medication.
Failure to Employ Qualified Full-Time Social Worker
Penalty
Summary
The facility, licensed for 154 beds, failed to employ a qualified social worker on a full-time basis as required for facilities with more than 120 beds. According to the facility census, there were 54 residents at the time of the survey. The Administrator confirmed during interview and record review that the previous social worker resigned about a month prior, and a replacement hired on 08/29/25 only worked for approximately one week before resigning for personal reasons. As of the time of the survey, the facility had just hired another social worker, scheduled to start on 10/07/25, leaving a gap in social work coverage. The Administrator also stated that, despite the company operating multiple facilities in town, he had not reached out for assistance with social services during this period. The facility's policy requires a social worker to manage psychosocial needs, grievances, and discharge planning, but these responsibilities were not fulfilled due to the absence of a qualified full-time social worker. This failure was identified through interviews and record reviews conducted by surveyors.
Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were resolved and that written decisions were issued, as required by policy. One resident, who was cognitively intact and had multiple medical diagnoses including GAD, bipolar disorder, DM2, HTN, CHF, and lupus, filed grievances regarding maintenance issues with her television and concerns about activities being conducted primarily in Spanish. Documentation revealed that the grievances were not fully addressed, with key sections of the grievance forms left blank, including the summary of findings, recommendations, actions taken, and the method of notifying the resident of the resolution. Record review of the facility's grievance binder showed a pattern of incomplete documentation, with several grievances in July, August, and September lacking evidence of resolution. Interviews with staff, including the Activities Director, Maintenance Assistant, Maintenance Director, and Administrator, confirmed that the grievances were not fully investigated or resolved. Staff acknowledged communication barriers and delays in addressing the resident's concerns, such as the lack of compatible TV remotes and the absence of cable service in the resident's room. The Administrator was aware of the unresolved issues but had not provided documentation of corrective actions or written decisions to the resident. The facility's grievance policy requires prompt efforts to resolve grievances and mandates that written decisions be issued to residents, including details such as the date received, summary of the grievance, investigative steps, findings, confirmation status, corrective actions, and the date of the written decision. Despite this, the facility did not follow its own procedures, resulting in unresolved grievances and a lack of communication with the resident regarding the outcomes of her complaints.
Failure to Complete Annual Employee Misconduct and Nurse Aide Registry Screenings
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not completing the required annual Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) screenings for one licensed vocational nurse (LVN). According to the facility's policy, all employees must be screened annually for any history of abuse, neglect, exploitation, or misappropriation of resident property by accessing the appropriate registries. However, record review and interview with the HR Coordinator revealed that the last annual EMR and NAR screening for the LVN in question was completed over a year prior to the review, and the subsequent screening was not performed until after the oversight was discovered. This lapse in following established screening procedures meant that the facility did not ensure ongoing compliance with its own abuse prevention policies and state requirements. The failure to conduct timely annual registry checks could have resulted in the continued employment of an individual who may have been listed for abuse, neglect, or exploitation, thereby not upholding the residents' right to be free from such mistreatment as outlined in the facility's policy.
Failure to Notify Ombudsman of Facility-Initiated Discharge
Penalty
Summary
The facility failed to provide required notification to the Office of the State Long-Term Care Ombudsman regarding a facility-initiated discharge for a resident. Specifically, when the resident was given a written discharge notice due to non-payment for a private room, the facility did not send a copy of this notice to the local Ombudsman at the same time as it was provided to the resident. Although the discharge notice stated that a copy had been sent to the Ombudsman, interviews and record review confirmed that this was not done. The resident involved had a complex medical history, including generalized anxiety disorder, bipolar disorder, diabetes mellitus type 2, hypertension, congestive heart failure, and lupus. She was alert and oriented, with a BIMS score indicating cognitive intactness, and was admitted from home. The care plan noted her need for 24-hour licensed nursing care and a history of making false accusations, as well as a preference for a private room due to PTSD. The discharge was initiated after the resident was unable to pay for a private room and did not qualify for Medicaid. Interviews with the local Ombudsman and facility Administrator revealed discrepancies in the facility's documentation and communication. The Ombudsman was not aware of the discharge notice and had not received a copy, despite the facility's policy and the Administrator's initial claim that the notice had been sent. The Administrator later confirmed that the required notification to the Ombudsman had not been completed as per regulatory requirements.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Protect Resident from Abuse and Inadequate Reporting of Allegation
Penalty
Summary
The facility failed to ensure that a resident was protected from abuse, neglect, and exploitation after the resident reported an incident of sexual abuse by a certified nursing assistant (CNA). The resident, who had vascular dementia, hemiplegia, hemiparesis, and required maximal assistance with activities of daily living, alleged that the CNA inappropriately touched him during a shower. The resident initially did not report the incident due to embarrassment but later disclosed it to staff. Despite this disclosure, the alleged perpetrator was not suspended, and the allegation was not investigated or reported to local law enforcement or the State Agency as required by facility policy and regulations. Multiple staff members became aware of the allegation through direct disclosure by the resident or through communication among staff. However, there was a breakdown in the reporting process, as some staff assumed others had reported the incident, and key individuals, including the ADON and charge nurse, did not ensure the allegation was escalated to the Administrator or documented appropriately. The Administrator stated she was not notified of the allegation and denied any knowledge of the incident. There was no documentation of the allegation in the resident's progress notes, 24-hour reports, or self-reports to the state agency during the relevant period. The facility's own abuse and neglect policy required immediate suspension of the alleged perpetrator, prompt investigation, and timely reporting to authorities, none of which occurred following the resident's report. The only action taken was to restrict male staff from providing care to the resident, without further investigation or protective measures for other residents. This failure to follow established protocols resulted in an Immediate Jeopardy situation, as residents were not protected from potential further abuse or harm.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 2 hours after the allegation was made. Specifically, a male resident with vascular dementia, hemiplegia, hemiparesis, and moderate cognitive impairment reported to staff that a certified nursing assistant (CNA) had sexually abused him during a shower. The resident initially delayed reporting the incident due to embarrassment, but later informed staff members, who did not immediately escalate the allegation to the facility administrator or law enforcement as required by policy and regulation. Multiple staff interviews revealed that the resident's report of sexual abuse was communicated among staff, including a medication aide, charge nurse, and assistant director of nursing (ADON), but there was confusion and lack of clarity regarding who was responsible for notifying the administrator and external authorities. The ADON stated that he informed the administrator by phone, but the administrator denied receiving any such report or having knowledge of the allegation. Documentation review showed no record of the abuse allegation in the resident's progress notes, 24-hour reports, or self-reports to the state survey agency during the relevant period. The CNA accused of abuse continued to work in the facility and was not suspended until months after the initial allegation. The facility's abuse/neglect policy required immediate reporting of all allegations to the administrator and appropriate authorities, but this protocol was not followed. Staff interviews indicated inconsistent understanding and execution of reporting procedures, with some staff assuming others had reported the incident. The lack of timely and proper reporting resulted in a failure to protect residents from potential further harm and did not meet regulatory requirements for abuse allegation management.
Removal Plan
- Abuse allegation investigations are ongoing. All new investigations start immediately upon receiving an allegation.
- The resident was interviewed at the time of discovery and a trauma informed care assessment was completed by the DON. Results were no negative outcomes.
- One on One in-service on Abuse Reporting with the Administrator, DON, by Area Director of Operation (ADO).
- One on One in-service on Investigating allegations with the Administrator, DON, by ADO.
- Staff working with alleged perpetrators have been interviewed by the Administrator, Director of Nursing, ADO, and Compliance Nurse.
- The alleged perpetrator was suspended, pending the outcome of the investigation.
- The ADON was suspended, pending the outcome of the investigation.
- Notification of Authorities: Law enforcement and HHSC were notified promptly in accordance with state-mandated reporting guidelines.
- Emotional Support: Social services and/or a mental health provider were contacted to provide counseling and emotional support to the resident; referral was sent.
- All residents who were able to be interviewed had safety surveys by the social worker. No abuse incidents were reported.
- All residents who were able to be interviewed were interviewed by DON/Compliance Nurse/Social worker. A new skin assessment was completed on all non-verbal residents by the same group with no abnormal findings.
- The following in-services were initiated by the Administrator/ADO: Any staff member not present or in-service will not be allowed to assume their duties until in-service.
- All Staff in-serviced on: Abuse/Neglect with special focus on sexual abuse; Abuse/Neglect Reporting; Who to Report Abuse/Neglect to Administrator and Director of Nursing. A second layer of reporting was added to prevent oversight of a single individual.
- All in-serviced staff will need to be able to articulate back on reporting any abuse allegation and to whom to report.
- The administrator/designee will assess and monitor understanding by quizzing and providing examples on in-services.
- New staff will be in service during orientation before assuming any duties.
- The medical director was notified of the immediate jeopardy situation.
- The administrator will report any abuse allegations, investigate, and submit findings to the Area Director and Risk Management for review.
- The administrator will submit documentation of the investigation with Resident and Staff interviews, as well as weekly follow-up interviews with staff and residents to ensure resident safety/satisfaction with the outcome of the investigation.
- The Area Director will monitor abuse allegations reported by residents and or staff and check the real-time system, which monitors keywords like abuse documentation and PCC for any incidents and accidents.
- The QA committee will review the findings of abuse allegations and investigations monthly and make changes to the system as needed until substantial compliance is achieved.
Failure to Investigate and Respond to Alleged Sexual Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a male resident with vascular dementia, hemiplegia, and moderate cognitive impairment. The resident reported that a CNA had inappropriately touched him during a shower, but the incident was not immediately or properly reported, documented, or investigated according to facility policy. Multiple staff members became aware of the allegation at different times, but there was confusion and lack of clarity regarding who was responsible for reporting the incident to administration, resulting in delays and incomplete communication. Despite the resident expressing discomfort and specifically requesting that the alleged perpetrator not provide care, the CNA continued to work in the facility and had access to other residents. There was no evidence that the alleged perpetrator was removed from resident care or suspended pending investigation until much later. Documentation in the resident's progress notes, 24-hour reports, and other records did not reflect the allegation or any investigation, and the administrator denied knowledge of the incident until it was brought to her attention by surveyors. Interviews with staff revealed inconsistent understanding and execution of abuse reporting protocols. Some staff assumed others had reported the incident, while others failed to document or escalate the allegation as required. The facility's own abuse/neglect policy required immediate investigation and administrative review, but these steps were not followed. The lack of timely and comprehensive response to the allegation resulted in a failure to protect the resident and prevent potential further abuse or mistreatment.
Failure to Develop and Implement Person-Centered Care Plan Reflecting Resident Preferences
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with specific preferences and needs identified in their assessment. The resident, a male with vascular dementia, hypertension, hemiplegia, hemiparesis, and lack of coordination, was admitted with moderate cognitive impairment. A Social Services Quarterly Assessment documented that no male CNAs should be in the resident's room, following an allegation of sexual abuse involving a male CNA. However, this preference was not reflected in the resident's care plan, and there was no documentation to ensure the preference was communicated or implemented. Multiple staff interviews revealed inconsistent awareness and understanding of the resident's preference regarding male CNAs. Some staff recalled being told verbally not to allow male CNAs in the resident's room, while others were unaware of any such instruction or the reason behind it. The social worker, who completed the assessment, was no longer employed, and the current social worker was unaware of the preference or its origin. Nursing staff and administration acknowledged that the information should have been included in the care plan but was not, and there was no documentation of the incident or the instructions given to staff. The facility's policy requires that each resident have a person-centered comprehensive care plan developed and implemented to meet their preferences and needs. Despite this, the resident's care plan did not address the documented preference for no male CNAs, and there was a lack of communication and documentation among staff to ensure the resident's needs and preferences were met as identified in the assessment.
Failure to Document Allegation of Sexual Abuse in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, there was no documentation in the resident's progress notes or 24-hour reports regarding an allegation of sexual abuse made by the resident. The resident, who had vascular dementia, hypertension, hemiplegia, hemiparesis, and lack of coordination, reported being inappropriately touched by a CNA during a shower. Although the resident initially did not report the incident due to embarrassment, he later informed facility staff. Interviews with staff revealed that the allegation was communicated among staff members, but none of the involved staff documented the incident in the resident's medical record or facility reports. The facility's own documentation policy requires that all observations, investigations, and communications involving resident care and treatments be recorded accurately and completely in the clinical record. Despite this, neither the nursing staff nor the interdisciplinary team ensured that the allegation was documented. The administrator confirmed that there was no documentation of the event, statements, or incident reports related to the allegation, emphasizing the importance of such documentation for continuity of care.
Lack of Privacy for Resident Phone Calls
Penalty
Summary
The facility failed to ensure that residents had reasonable access to a telephone and a private place to make calls without being overheard. This deficiency was observed in the cases of three residents who were reviewed for telephone use. Resident #17, who was cognitively intact, was seen using a phone at the nurses' station, where other residents and staff were in close proximity, compromising his privacy. The phone in the chapel, which was supposed to offer privacy, was not operational due to ongoing construction, leaving residents without a private option. Interviews with staff and residents revealed that the lack of privacy was a common issue. LVN C acknowledged the need for privacy and mentioned that the chapel phone was not working. CNA A and the Social Worker also confirmed the privacy concerns, with the Social Worker admitting she was unsure if she had been trained on residents' rights to privacy. Residents expressed discomfort and embarrassment due to the lack of privacy, with some preferring to use the phone at the nurses' station despite the presence of others. The facility's policy on resident rights, which includes the right to private phone calls, was not adhered to. The Administrator and DON acknowledged the privacy violation, with the Administrator noting that the chapel phone was supposed to be functional but was not. The deficiency was further highlighted by the fact that some staff were unaware of the residents' need for privacy during phone calls, and the available cordless phones did not provide adequate coverage for private use in residents' rooms.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #39, who has diabetes and peripheral vascular disease, was not seen by a podiatrist, resulting in long, yellow, and chipped toenails. Despite having a care plan that included podiatry services, there was no physician's order for podiatrist services, and the resident had not been seen by a podiatrist in five months. The facility's staff, including CNAs and nurses, failed to document the need for toenail care, and there was a lack of communication and follow-up regarding the scheduling of podiatry appointments. Resident #33, who has severe cognitive impairment and dementia, exhibited wandering behavior that was not addressed in her care plan. The resident was observed entering other residents' rooms, mistakenly believing they were her own. Although staff were aware of her wandering behavior, there were no documented interventions in her care plan to address this issue. The MDS Coordinator and Social Worker acknowledged the oversight and the lack of a system for reporting resident behaviors to ensure they are included in care plans. The facility's policy and procedure manual on comprehensive care planning requires that each resident have a person-centered care plan that addresses their medical, physical, and psychosocial needs. However, the facility failed to adhere to this policy, resulting in inadequate care for Residents #39 and #33. The lack of proper documentation, communication, and follow-up contributed to the deficiencies observed during the survey.
Failure to Provide Adequate Foot Care for Residents
Penalty
Summary
The facility failed to provide proper foot care for two residents, leading to deficiencies in maintaining their foot health. Resident #39, a cognitively intact woman with diabetes and peripheral vascular disease, did not receive timely podiatry services. Despite having a care plan that required regular podiatrist visits and toenail maintenance, there was no record of a podiatrist appointment for her. Observations revealed her toenails were overgrown and discolored, and interviews with staff indicated a lack of communication and documentation regarding her need for podiatry care. Resident #62, who has severe cognitive impairment and requires assistance with personal care, also did not receive adequate foot care. Her care plan included regular toenail checks and trimming, but observations showed her toenails were long, thick, and discolored. The last podiatrist visit was several months prior, and there was no follow-up appointment scheduled. Staff interviews revealed that the responsibility for scheduling podiatrist appointments had recently changed hands, leading to lapses in care. The facility's policy required daily foot assessments and podiatrist referrals for residents with conditions like diabetes. However, there was a breakdown in the process, with CNAs failing to document and report long toenails, and nurses not scheduling necessary appointments. This lack of coordination and adherence to policy resulted in residents not receiving the foot care they needed, putting them at risk for complications.
Failure to Maintain Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, Resident #26 and Resident #39, by not maintaining clean oxygen concentrator filters. For Resident #26, who has a medical history of Chronic Obstructive Pulmonary Disease (COPD) and moderate cognitive impairment, the oxygen concentrator filter was observed to be dirty with debris. Interviews with staff revealed that the responsibility for cleaning the filters was assigned to CNAs and nurses on the night shift every Friday. However, the order for weekly cleaning had been discontinued by a nurse who was no longer employed, and no documentation was provided to justify this change. Resident #39, who has diagnoses including hypoxia, asthma, and COPD, was also found to have a thick coat of dust on the oxygen concentrator filter. The care plan for Resident #39 did not address the cleaning of the oxygen concentrator filter, and the order for weekly cleaning had been discontinued. Interviews with staff indicated that the cleaning should occur weekly, but the responsibility was not clearly enforced, leading to the observed deficiency. The facility's policy and the manufacturer's manual both require that oxygen concentrator filters be cleaned weekly with soap and water and allowed to air dry completely. The failure to adhere to these guidelines and maintain clean filters could impair the performance of the oxygen concentrators and pose risks to the residents' health. The Director of Nursing confirmed the discontinuation of the cleaning orders but was unaware of the reasons behind it.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies related to medication management. Observations and interviews revealed that the facility did not have a reliable system for the accurate reconciliation of controlled substances. Specifically, the Controlled Substance Medication Count Record for certain rooms showed blanks in documentation, indicating that the on-coming and off-going nurses did not verify and sign off on the controlled substances count as required. This lapse was confirmed by an LVN who admitted to signing the record before actually counting the substances, which could lead to drug diversion. Additionally, the facility did not maintain proper storage conditions for medications. Observations showed that liquid medications in the medication carts had dried drippings on the sides of the bottles, and some bottles were not dated when opened, contrary to the manufacturer's instructions. Medications were not stored separately according to their routes of administration, and the sharps disposal container was overfilled, posing a safety risk. These issues were noted in the medication carts on two different halls, indicating a broader problem with medication storage practices. Furthermore, the facility failed to update medication labels following changes in physician orders. An instance was observed where a pharmacy label for a resident's medication did not reflect a change in dosage and administration frequency, as per the new physician's order. This oversight was only corrected after being pointed out by a state surveyor, highlighting a risk of administering incorrect medication dosages. Interviews with facility staff revealed that while training on these procedures was provided, the implementation was inconsistent, leading to these deficiencies.
Failure to Refrigerate Opened Probiotic Supplement
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not refrigerating an opened bottle of Acidophilus Probiotic Dietary Supplement as required by the manufacturer's label. During an observation on the 4th floor, a Medication Aide's cart was found to contain the probiotic supplement, which had been opened on 11/03/24 and was not refrigerated. LVN B confirmed the oversight and immediately removed the bottle from the cart. This failure could potentially affect the availability and efficacy of medications for residents by not adhering to the manufacturer's storage specifications.
Deficiencies in Food Storage and Sanitation Procedures
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Foods in the refrigerator were not stored in sealed containers, and one of the spice bottles on a metal storage rack was not completely sealed. Additionally, the kitchen ceiling tiles were not maintained properly, with dried brown water stains present, and ceiling vents above the food preparation area were covered in lint. Missing ceiling tiles were noted in the room between the kitchen and the dishwashing room, as well as in the dry storage room. The vegetable sink was not operational, and the trash can next to the handwashing sink was broken, with a cracked lid and a non-functional foot pedal. The facility also failed to follow the Three-Compartment Sink Procedures for sanitizing pots and pans. During an observation, a dietary staff member was seen washing and rinsing a pan and then quickly dipping it in and out of the sanitizer compartment, contrary to the posted instructions that required immersion for at least one minute. The dietary manager confirmed that staff had been trained to follow these procedures, but the staff member admitted to not following them due to nervousness. The registered dietitian confirmed that the sanitizing solution used required a one-minute immersion. The facility's dietary services policy and procedure manual, dated 2012, outlined the requirements for food storage and equipment sanitation, which were not followed. The manual specified that all open packages of food should be stored in closed containers or sealed bags and dated. It also detailed the proper sanitizing methods for equipment and utensils, which were not adhered to during the survey. These deficiencies in food storage, kitchen maintenance, and sanitation procedures could potentially lead to foodborne illnesses among residents.
Infection Control Deficiencies in Hand Hygiene and Storage Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observations and interviews. During a meal service, an LVN was observed distributing meal trays without performing hand hygiene after repositioning a resident, which contradicts the facility's policy requiring hand hygiene between resident interactions. Interviews with staff, including the DON and other nurses, confirmed that hand hygiene is a critical component of infection control training, yet there was inconsistency in its application. The facility's Infection Control Policy mandates hand washing after each direct resident contact, but this was not adhered to during the observed meal service. Additionally, the facility did not ensure proper storage of medical supplies and personal belongings, which could lead to cross-contamination. An open package of gauze non-sterile sponges was found on a treatment cart, and personal belongings were improperly stored on a clean linen table shelf. The housekeeping supervisor and staff confirmed that clean linen should be stored in covered carts and personal items should not be stored in areas designated for clean linen. These lapses in protocol could contribute to the spread of infections within the facility.
Deficiency in Maintaining Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations during initial rounds revealed that several resident rooms had closet doors that were either missing or off their tracks, lacking the necessary Sliding Closet Door Bottom Guide. This guide is essential to prevent the doors from swinging or derailing, which could lead to potential injuries. Interviews with the Social Worker and the Administrator highlighted a lack of communication and awareness regarding the issue, as the Social Worker had not reported the loose doors to the relevant authorities, and the Administrator acknowledged the potential hazard posed by the malfunctioning doors. Further observations with the Maintenance Supervisor confirmed that the closet doors were indeed off the tracks and lacked the necessary guides, posing a risk of falling and causing injury. The Maintenance Director demonstrated that some doors were jammed due to obstructions inside the closets, exacerbated by the absence of the bottom guide. The facility's Social Service Manual emphasizes the residents' right to a safe and comfortable environment, yet the current state of the closet doors contradicts this policy, indicating a deficiency in maintaining essential equipment in safe operating condition.
Failure to Ensure Call Light Accessibility for Resident with Physical Limitations
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for their needs and preferences. The resident, who has severe cognitive impairment and physical limitations due to Parkinson's disease, cerebellar ataxia, seizures, and traumatic brain injury, was observed lying in bed with the call bell clipped on the overhead light, out of reach. The resident's care plan specifically included an intervention to keep the call light within reach due to their risk for injury related to a seizure disorder. Interviews with facility staff revealed a lack of communication and adherence to the care plan. A CNA acknowledged that the resident could not use the call light due to bilateral hand contractures and stated that the resident was checked every 15 minutes or would yell for assistance. However, the ADON and LVN indicated that a pad call light should have been provided, as the resident could use it with their left hand. The facility did not have a call light policy, and the staff had not reported the resident's inability to use a regular call light, resulting in the deficiency.
Failure to Respect Resident's Privacy and Dignity
Penalty
Summary
The facility failed to ensure that residents had the right to be treated with respect and dignity, specifically for one resident who experienced an incident where a nurse entered his room without permission after knocking. This incident occurred when the resident was naked, leading to feelings of embarrassment and a loss of dignity. The resident had a history of making false accusations and negative statements about staff, but his cognitive abilities were intact, and he was independent in his activities of daily living. The resident reported the incident to the Social Worker and the Ombudsman, stating that a nurse entered his room without his approval while he was naked. The nurse later refused to give her name when asked by the resident. The facility's Social Worker and Administrator acknowledged the resident's grievance and recommended that staff knock and wait for permission before entering a resident's room. However, the Social Worker also mentioned that staff have the right to enter a room if there is no response to ensure the resident's safety. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity. Despite this policy, the incident with the resident was not adequately addressed, as the nurse involved did not respond to follow-up calls, and the grievance remained unresolved. The Administrator confirmed that staff should knock and wait for permission to enter but may need to enter without permission in case of an emergency, especially for residents with a history of falls.
Violation of Resident's Right to Receive Unopened Mail
Penalty
Summary
The facility failed to ensure that residents received unopened mail, violating their right to privacy. Specifically, Resident #8 received a letter from a family member that was opened before it was delivered to him. The resident, who is cognitively intact with a BIMS score of 15, reported the issue to the Ombudsman and the facility's staff. The Business Office Manager (BOM) and BOM Assistant admitted to opening mail for residents unless they were on a specific list, which included Resident #8. Despite this, the BOM Assistant mistakenly opened Resident #8's mail, leading to the grievance filed by the resident. Interviews with various staff members, including the Social Worker, Activities Director, and Administrator, confirmed that the facility had a policy to deliver unopened mail to residents unless the facility was the representative payee. However, the BOM and BOM Assistant's actions contradicted this policy, as they routinely opened mail to determine its recipient. The facility's in-service training record and a list provided by the BOM highlighted residents who should receive unopened mail, but this protocol was not consistently followed. Resident #8's grievance was documented, and the Social Worker attempted to address the issue by ensuring the Activities Director would personally deliver the resident's mail. Despite this resolution, the initial failure to deliver unopened mail to Resident #8 represents a clear violation of resident rights. Interviews with other residents revealed that they did not receive their mail at the facility, further indicating systemic issues with mail handling and delivery.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse when an altercation occurred between two residents. On the morning of the incident, Resident #2 verbally threatened Resident #1, but this was not reported or investigated by the staff. Later that day, Resident #2 physically assaulted Resident #1 in the dining room, resulting in a physical altercation. The staff present did not intervene in time to prevent the assault, and the incident was not properly reported or investigated by the facility's administration. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, was not adequately protected from Resident #2. Despite Resident #1's known history of wandering and anxiety, the facility did not take sufficient measures to monitor and redirect him. Resident #2, who has a history of adverse behavior and is diagnosed with schizoaffective disorder and dementia, was also not adequately monitored or redirected, leading to the physical altercation. The facility's failure to investigate the initial verbal threat and to protect Resident #1 from Resident #2 resulted in a physical altercation that could have been prevented. The facility's policies on abuse prevention and reporting were not followed, putting residents at risk of harm. The administrator, who is the Abuse Coordinator, was not informed of the initial verbal threat, and the incident was not investigated to determine the root cause and implement a plan to maintain safety for all parties involved.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement written policies that prohibit and prevent abuse, neglect, and exploitation of residents, specifically for two residents involved in altercations. On 02/26/2024, Resident #1 and Resident #2 were involved in a physical altercation where Resident #2 struck Resident #1 on the left cheek. This incident was not properly investigated, and the facility did not take necessary measures to protect Resident #1 from further harm. Additionally, an earlier verbal threat made by Resident #2 towards Resident #1 on the same day was not reported or investigated, which could have prevented the subsequent physical altercation. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, was not adequately monitored or protected. His care plan included interventions for anxiety and aggressive behavior, but these were not effectively implemented. Resident #1 had been wandering and displaying signs of agitation in the days leading up to the incident, yet staff failed to intervene appropriately to prevent the altercation. Resident #2, who has a history of schizoaffective disorder and other behavioral disturbances, also had a care plan that included monitoring for aggressive behavior. Despite this, the facility did not take adequate steps to separate the residents or address the verbal threat made by Resident #2 earlier in the day. The lack of timely intervention and failure to report the initial verbal threat contributed to the physical altercation that occurred later in the day.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately or within 24 hours to the administrator and other officials. This deficiency was observed in the case of two residents who were involved in an altercation. LVN C did not report the incident where Resident #2 made contact with Resident #1's left cheek after becoming agitated. This incident occurred in the morning, but it was not reported to the Administrator, putting residents at risk of physical altercations that could result in injury. Resident #1, who has severe cognitive impairment and a history of aggressive behavior, was involved in the altercation with Resident #2. Resident #1's care plan included interventions to monitor and report any mental status changes, place him in a quiet area when anxiety occurs, and redirect him during episodes of adverse behavior. Despite these measures, the altercation occurred, and the incident was not reported as required. Resident #2, who has diagnoses including Parkinson's disease, depression, anxiety, and schizoaffective disorder, was also involved in the altercation. His care plan included monitoring for adverse behavior and removing him from unwanted stimuli. However, the incident where he verbally threatened and physically assaulted Resident #1 was not reported to the Administrator. The failure to report this incident and investigate it properly highlights a significant lapse in the facility's abuse prevention and reporting protocols.
Failure to Address Wandering Behaviors in Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain his highest practicable well-being. The resident, who had a history of aggressive behavior and severe cognitive impairment, exhibited ongoing wandering behaviors that were not adequately tracked or addressed. Despite being identified as at risk for wandering, the resident's care plan lacked specific interventions to manage these behaviors effectively. The facility's failure to monitor and document the resident's wandering behaviors placed him at risk of harm, including verbal and physical abuse from other residents. The resident's medical records revealed multiple instances of wandering and anxiety, with attempts at redirection often being unsuccessful. Progress notes documented the resident's wandering behaviors, including entering other residents' rooms and becoming verbally aggressive. However, there were no consistent orders for tracking these behaviors in the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) until March 2024, and even then, the monitoring was inconsistent. Interviews with facility staff, including the Director of Nursing (DON), indicated a lack of awareness and proper assessment of the resident's wandering behaviors. The DON acknowledged the importance of accurate care plans but stated that the resident's wandering was not considered problematic unless it involved exit-seeking behavior. The facility's dementia policy emphasized the need for a systematic approach to care, including the development of a care plan with specific interventions, which was not adequately followed in this case.
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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