Heritage Plaza Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Texarkana, Texas.
- Location
- 600 W 52nd St, Texarkana, Texas 75501
- CMS Provider Number
- 675561
- Inspections on file
- 34
- Latest survey
- September 10, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Heritage Plaza Nursing Center during CMS and state inspections, most recent first.
A resident with a history of abnormal weight loss and a recent ankle fracture experienced significant weight loss, poor intake, and swallowing difficulties. Despite staff observations and recommendations from the wound care physician, the care plan was not updated, and no dietician consult or therapeutic diet was provided in a timely manner. Staff attempted informal interventions, but there was no formal change in diet or coordinated response to the resident's nutritional decline.
Surveyors found that food items in the kitchen, including powdered sugar, mixed vegetables, and various meats, were not properly stored, labeled, or dated as required by facility policy. Staff interviews confirmed that these practices were not followed, and items with unknown storage times or improper sealing were present in both the refrigerator and freezer.
Three residents had broken dressers or wardrobes with missing or damaged drawer fronts and exposed personal items, while the dining room activity cabinet had removed doors left propped nearby. Staff and maintenance were either unaware or had not reported these issues, and no work orders were submitted for repairs. The facility's maintenance policy required all areas and equipment to be kept in good repair, but this was not followed.
Multiple infection control failures were observed, including staff not using required PPE or signage for a resident on droplet precautions, improper glove use and hand hygiene during catheter care for a resident with severe cognitive impairment, and failure to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during wound and incontinent care for a resident with wounds. Staff interviews confirmed knowledge of protocols but inconsistent adherence during care.
A resident with severe cognitive impairment and a Foley catheter was repeatedly observed without a privacy bag covering the catheter drainage bag, making it visible in both the resident's room and public areas. Staff interviews confirmed awareness of the requirement for privacy bags to maintain dignity, but the absence was not reported or corrected, and the facility's policy did not address dignity.
Two residents with cognitive impairment and documented needs for socialization did not receive consistent, scheduled activities as outlined in their care plans and physician orders. Activity participation records were not updated, and residents reported limited engagement, with activities often canceled or not started on time. Staff interviews confirmed that the Activity Director's additional duties interfered with the delivery of the activity program, resulting in a lack of variety and frequency of activities.
The facility did not employ a certified Activity Director to oversee its activities program. The individual in the role lacked the required certification and had limited experience, having previously worked as a CNA and in transportation. The Activity Director was enrolled in a certification course but had not yet started it, and continued to perform other duties in the facility. Facility policies did not specify the necessary qualifications for the position.
A resident with dementia and impaired mobility was transferred using a mechanical lift by a CNA who did not open the lift's legs to the wide position before lifting and moving the resident, as required by facility policy and best practices. The legs were only spread after the resident was already suspended and being moved, following a prompt from another CNA. Interviews and policy review confirmed this was not in accordance with safe transfer procedures.
A resident with an indwelling Foley catheter did not receive proper catheter care, including failure by a CNA to change gloves and perform hand hygiene after cleaning the resident, lack of a catheter securement device, and the catheter drainage bag being left on the floor. Staff interviews confirmed awareness of proper procedures, but these were not followed during the observed care.
A resident with a documented history of PTSD did not receive a trauma screening or assessment upon admission, despite facility policy and clear documentation of trauma history. The care plan did not address PTSD or identify potential triggers, and staff interviews confirmed the required screenings and assessments were not completed or documented.
A resident with a history of diverticulitis and an ileostomy was found covered in feces due to a leaking colostomy bag, highlighting a failure in providing dignified care. Despite the resident's and family's complaints, staff did not respond promptly, leaving the resident in distress for hours. Interviews revealed confusion among staff about responsibilities for colostomy care, contributing to the incident.
The facility failed to ensure call lights were within reach for two residents, both with cognitive impairments and fall risks. One resident's call light was found hanging on a curtain, while another's was on the floor, making them inaccessible. Staff interviews confirmed the expectation for call lights to be within reach to prevent falls and ensure timely assistance.
A resident with severe cognitive impairment was verbally abused by a CNA during shower assistance. The CNA accused the resident of lying and made derogatory comments, which were overheard by the previous DON. The incident was documented, and the resident did not appear to be in distress or injured, but the comments were deemed abusive.
A resident with a colostomy experienced multiple incidents of leaking bags, resulting in her being covered in feces for several hours. The facility staff were not adequately trained or informed about their responsibilities in managing colostomy care, leading to delays in addressing the leaks. The resident's call light was not answered promptly, and staff were unclear about their roles, resulting in the resident remaining in a soiled state.
A resident with severe cognitive impairment and multiple medical conditions frequently refused care, including repositioning and medication intake. Despite these refusals being noted in assessments, the facility failed to update the care plan to reflect these issues, leaving staff without proper guidance. Interviews with staff revealed a lack of clarity and responsibility in updating the care plan, leading to the deficiency.
A facility failed to implement its abuse prevention policies when a resident was roughly handled by a CNA during ADL care. The CNA was not suspended immediately, and the abuse was not reported to the state agency within the required timeframe. The resident, who had chronic health conditions and required assistance, was upset by the mistreatment. Despite being informed, the ADON delayed reporting the incident, allowing the CNA to continue working for several shifts. The facility's noncompliance was identified as PNC.
The facility failed to provide adequate supervision and safe practices for two residents, leading to a fall and injury during incontinent care and unsafe mechanical lift transfers. A resident with severe cognitive impairment fell off the bed during care by a single CNA, despite requiring two-person assistance. Another resident was transferred alone using a mechanical lift, contrary to care plan requirements. Staff reported frequent understaffing, contributing to these unsafe practices.
Two residents in a LTC facility were not treated with dignity and respect. One resident was denied assistance by a CNA when he requested to be repositioned in bed, while another resident was subjected to an inappropriate comment by the previous Administrator, comparing his appearance to that of a child molester. Both incidents were reported by staff and family, highlighting a breach of the residents' rights.
Two residents in a LTC facility experienced abuse by CNAs, one physically and the other verbally. The first resident, with mild cognitive deficit and multiple health issues, was roughly handled during bed transfer, while the second resident, with dementia and limited mobility, was subjected to inappropriate language during a verbal altercation. Both incidents violated the residents' rights and the facility's abuse policy.
A resident with chronic health issues and mild cognitive deficit experienced rough and verbally harsh treatment by a CNA, which was captured on video by the resident's family. The ADON was informed of the incident but delayed reporting it to the abuse coordinator and authorities, unaware of the 2-hour reporting requirement. The facility's policy mandates immediate reporting of abuse allegations, but the incident was reported to HHS eight days later.
The facility failed to provide a private space for Resident Council meetings, leading to continuous interruptions by staff. Despite the facility's policy that meetings should be private, staff entered the dining room during meetings, compromising residents' ability to voice their concerns without interference. The Administrator acknowledged the issue and the availability of alternative routes for staff to avoid disrupting the meetings.
A resident with multiple fractures and chronic pain did not receive the ordered Lidocaine 5% topical patch for several days after admission. The medication aide forgot to administer the patch, leading to ongoing pain for the resident. The Director of Nursing and Administrator confirmed the oversight, acknowledging it was against the facility's pain management policy.
The facility failed to lock medication carts and remove expired medications, posing risks of drug diversion and adverse reactions. Unlocked carts with various medications were observed, and expired eye drops were found in one cart. Staff acknowledged the policies but did not consistently follow them.
The facility failed to promote resident self-determination for two residents. One resident was not assisted out of bed as often as she preferred, and another was not provided with showers or shaves as requested. Both residents expressed dissatisfaction with their care, and staff confirmed issues with adhering to personal care schedules due to understaffing.
A facility failed to maintain a safe and comfortable environment for a resident with severe cognitive impairment and depression. The wall behind the resident's bed had multiple areas of damage, which had been reported but not repaired for months. Staff acknowledged the delay and the need to move the resident for the repair, but the family had been non-compliant in moving the resident's camera.
The facility failed to provide scheduled bathing and grooming services to two residents, leading to poor personal hygiene and unmet care needs. One resident did not receive scheduled showers, and another was not shaved as per his preference, despite both requiring assistance with activities of daily living.
The facility failed to provide a resident with consistent, scheduled activities and an activity calendar, despite the resident being cognitively intact and expressing interest in participating. The resident reported feeling ignored and was often found in bed, missing group activities. Staff interviews and observations confirmed the lack of engagement and documentation of activity refusals.
A facility failed to provide a catheter securement device for a resident with an indwelling urinary catheter, leading to increased risks of urethral trauma, dislodgement, infection, and skin breakdown. The oversight was confirmed through observations and staff interviews, revealing that the securement device had been missing for several hours.
A facility failed to ensure safe and sanitary storage of a resident's food items, leading to expired and decomposing meat products being found in the resident's personal refrigerator. Despite being informed, the housekeeping staff did not remove the expired food, and the Director of Nursing and Administrator acknowledged the oversight, highlighting a risk of foodborne illness.
Failure to Provide Therapeutic Diet and Timely Interventions for Resident with Nutritional Decline
Penalty
Summary
A deficiency occurred when the facility failed to ensure a therapeutic diet was offered and appropriate interventions were implemented for a resident experiencing nutritional problems, including poor intake related to swallowing difficulties and physical decline. The resident, an older female with a history of abnormal weight loss, was admitted with a left ankle fracture and subsequently developed a wound after cast removal. Despite documented weight loss, low prealbumin levels, and decreased oral intake, the care plan was not updated in a timely manner to reflect these changes, and no dietician consult was initiated as recommended by the wound care physician. Staff interviews and record reviews revealed that the resident's care plan had not been revised to address her weight loss, swallowing issues, or wound care needs since several months prior. The resident's diet remained unchanged, and although staff observed her difficulty swallowing and poor appetite, no formal order was placed to modify her diet consistency. The dietary manager and aides noted the resident's decreased intake and attempts to provide softer foods, but these actions were not supported by updated physician orders or care plan interventions. The speech therapist was only informally consulted and did not complete a formal assessment until much later. Multiple staff members, including nurses, aides, and dietary staff, reported the resident's declining intake and difficulty swallowing over a period of weeks. Despite these observations and the resident's significant weight loss, there was a lack of communication and follow-through to ensure appropriate dietary and therapeutic interventions were implemented. The facility's own policies required notification of the physician and dietitian for significant weight changes, but these steps were not taken in a timely manner, resulting in the resident not receiving the necessary nutritional support.
Failure to Properly Store, Label, and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, labeling, and dating of food items. An opened box of powdered sugar was found in the dry goods pantry with the inner plastic bag cut open and not securely closed, nor was it placed in a sealed, labeled, and dated container. In the refrigerator, a clear plastic container with a red sauce and another with mixed vegetables (green beans, corn, and potatoes) were found without any labels or dates. Staff interviews confirmed that the red sauce was recently placed in the refrigerator, but the mixed vegetables' storage duration was unknown. Both items were discarded after discovery due to improper labeling and dating. Further inspection of the freezer revealed two plastic bags containing meat—one with an unknown type of meat and another with what appeared to be chicken—both covered in ice particles and lacking labels and dates. Staff interviews indicated that food items should be labeled and dated before being placed in storage, and that the presence of ice on meat could indicate freezer burn and improper storage duration. Staff acknowledged their responsibility for proper food storage, with the dietary manager (DM) ultimately accountable for ensuring compliance. The facility's policy requires all opened food packages to be stored in airtight containers or bags, accurately labeled with the item and date opened, and all foods in the refrigerator and freezer to be covered, labeled, and dated. The observed deficiencies in food storage, labeling, and dating were confirmed by staff and management interviews, as well as a review of facility policy, but no specific residents or patient conditions were mentioned in relation to the deficiency.
Failure to Maintain Resident and Common Area Furniture in Good Repair
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for three residents and the dining room, as evidenced by multiple pieces of furniture in disrepair. Observations revealed that one resident's dresser was missing the front of a bottom drawer, exposing personal clothing items, with worn and exposed wood. Another resident's dresser was missing the front of a drawer, also exposing personal items, and a third resident's wardrobe had a top drawer front hanging down and a door handle with a missing screw. In each case, the residents reported that the furniture had been broken for a long time and had not been reported to staff. Staff interviews indicated a lack of awareness and reporting regarding the broken furniture. A CNA stated she had not noticed any broken furniture but acknowledged that any staff entering a room should report such issues. An LVN admitted to noticing missing drawer fronts but never reported them. The Maintenance Supervisor was unaware of the specific furniture issues in the residents' rooms and stated that repairs were made only when work orders were submitted or when he noticed issues himself. The Maintenance Work Order book contained no entries for the broken furniture in question. Additionally, the activity cabinet in the dining room was observed to have its right-side doors removed and propped against another cabinet. The Maintenance Supervisor was aware of the broken cabinet but had not received approval to replace it and had no extra furniture available. The facility's maintenance policy required the building and equipment to be maintained in good repair and free from hazards, but these requirements were not met in the cases observed.
Infection Control Lapses in Isolation, Catheter, and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in infection control practices for several residents. For one resident with a post-COVID-19 condition and COPD, staff did not place appropriate signage or a PPE supply cart outside the resident's room to indicate the need for transmission-based droplet precautions. Staff members, including CNAs, entered the resident's room without wearing required PPE, and some were unaware of the resident's isolation status. Interviews revealed that staff did not consistently know or follow the facility's infection control policies regarding isolation precautions. Another resident with severe cognitive impairment and an indwelling urinary catheter received catheter care from a CNA who failed to change gloves and perform hand hygiene after cleaning the resident's buttocks. The CNA continued to handle clean linens and reposition the resident without changing gloves or sanitizing hands. Both the CNA and other staff interviewed acknowledged the importance of glove changes and hand hygiene but did not consistently apply these practices during care. Additionally, a resident with wounds and requiring Enhanced Barrier Precautions (EBP) did not receive care in accordance with EBP protocols. During wound care and incontinent care, staff did not wear gowns as required, despite the presence of indicators (blue name tags) signaling the need for EBP. Staff interviews confirmed knowledge of the EBP requirements but revealed lapses in adherence, with staff admitting to not wearing gowns during high-contact care activities. These failures were observed during direct care and confirmed through staff interviews and record reviews.
Failure to Maintain Resident Dignity by Not Using Catheter Privacy Bag
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, chronic kidney disease, and an indwelling Foley catheter was repeatedly observed without a privacy bag covering the catheter drainage bag. Observations on multiple occasions showed the drainage bag was visible from the doorway and in public areas, with no privacy bag in place, despite care plan interventions and physician orders specifying the use of a privacy bag to maintain dignity. The resident was non-interviewable due to cognitive impairment. Interviews with CNAs, an LVN, the DON, and the Administrator confirmed that staff were aware of the expectation to use privacy bags for catheter drainage bags to promote resident dignity. Staff acknowledged the absence of the privacy bag and indicated that it should have been reported and replaced. Review of the facility's Resident Rights policy revealed it did not address dignity, and the failure to ensure the privacy bag was in place was not identified or corrected by staff prior to the survey.
Failure to Provide Consistent, Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of two residents. Both residents had documented needs for socialization and activity participation, with care plans and physician orders specifying activities as tolerated. However, records showed a lack of consistent, scheduled activities, and daily participation forms had not been updated for either resident since February, despite their previous engagement in most activities except aromatherapy and manicures. Observations and interviews revealed that both residents expressed dissatisfaction with the lack of variety and frequency of activities, noting a decline in available options since the previous Activity Director left. One resident reported that the only activity offered was bingo, and both described feeling bored and lacking stimulation. Scheduled activities on the facility's calendar were not consistently carried out, with documented instances where activities were canceled or not started on time, and residents were left without engagement during scheduled activity periods. Staff interviews confirmed the inconsistency in the activity program. The Activity Director, who also held restorative aide and van driver duties, acknowledged that her additional responsibilities interfered with her ability to provide scheduled activities. Other staff members, including a CNA and LVN, noted the limited activities and recognized the potential impact on residents' mental and physical well-being. The DON and Administrator were aware of the dual roles held by the Activity Director and the resulting challenges in maintaining the activity schedule.
Unqualified Activity Director Leading Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required. Review of the personnel file for the Activity Director revealed that the individual did not possess an Activity Director Certification and had only two years of experience in a social or recreational program. The Activity Director had been hired in January and previously worked as a CNA and in transportation, with no prior experience as an activity director. She reported having completed only one training class and was not yet certified, although she was enrolled in a certification course scheduled to begin in several months. During this period, she also performed duties as a restorative aide and occasionally drove the facility van. Interviews with the Activity Director and the Administrator confirmed that the Activity Director was not certified and had limited experience in the role. The Administrator acknowledged that the Activity Director was receiving support and oversight from another individual but confirmed that the required certification had not been obtained. Review of the facility's policies and procedures for wellness and life enrichment activities did not specify the required qualifications for the Activity Director position.
Failure to Perform Safe Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform a safe mechanical lift transfer for a resident with dementia, heart failure, hypertension, and anxiety. The resident, who weighed 250.2 pounds and was at risk for falls with impaired physical mobility, required assistance with transfers. During an observed transfer from bed to a high back wheelchair, the CNA did not open the legs of the mechanical lift to the wide position before lifting and moving the resident, contrary to facility policy and manufacturer guidelines. The transfer was conducted with the lift pad already under the resident, and both CNAs attached the straps to the mechanical lift. The primary CNA lifted the resident without spreading the lift legs, then moved the resident suspended in the lift pad out from over the bed and toward the wheelchair. The legs of the lift were only spread to the wide position after the resident was already being moved, following a prompt from the assisting CNA. The resident was then lowered into the wheelchair and positioned for comfort. Interviews with the assisting CNA, the primary CNA, the DON, and the administrator confirmed that the mechanical lift legs should be opened wide prior to lifting for stability and to prevent tipping. The facility's policy and FDA best practices both require the lift base to be at its maximum open position during transfers. The DON was unable to locate the mechanical lift competency check-off form for the CNA who performed the transfer.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, and an indwelling Foley catheter did not receive appropriate catheter care as required by facility policy and physician orders. During an observed catheter care procedure, a CNA failed to change gloves and perform hand hygiene after cleaning the resident’s buttocks and before handling clean linens and clothing. The same gloves were used throughout the process, and the CNA was uncertain about the correct protocol for glove changes and hand hygiene. Another CNA present did not intervene or clarify the procedure, despite recognizing the lapse. Additionally, the resident’s Foley catheter was not secured with a catheter securement device as required by the care plan and treatment orders. Both CNAs and the LVN confirmed that the securement device was missing and acknowledged its importance in preventing injury from catheter pulling. The absence of the securement device was not reported to the nurse, and the LVN was unaware of its omission until the surveyor’s observation. The resident’s Foley catheter drainage bag was also observed touching the floor after the bed was lowered by a CNA. Both CNAs and the LVN recognized that the drainage bag should not be on the floor, as per facility policy, but the issue was not corrected during care. Interviews with staff, including the DON and Administrator, confirmed expectations for proper catheter care, use of securement devices, and keeping drainage bags off the floor, but these standards were not met during the observed care for this resident.
Failure to Complete Trauma Screening and Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a known history of trauma and a diagnosis of PTSD received trauma-informed, culturally competent care in accordance with professional standards. Upon admission, the resident's records, including the admission referral packet, MDS assessment, and admission assessment, all documented a diagnosis of PTSD and a history of trauma. Despite this, there was no evidence that a trauma screening or trauma assessment was completed upon admission or at any point since admission. The resident's comprehensive care plan did not address PTSD or identify potential triggers for re-traumatization, and social services notes also lacked any trauma screening or identification of triggers. Interviews with facility staff, including the Social Services Director, DON, and Administrator, confirmed that trauma screenings were expected to be completed upon admission and that a positive screening should trigger a more comprehensive assessment. However, staff were unable to locate any trauma screening or assessment for the resident in the medical record, and there was uncertainty regarding whether a diagnosis of PTSD would automatically trigger further assessment. The facility's own policy required trauma screening upon admission, annually, and as needed, with identified triggers to be incorporated into the care plan, but this was not followed for the resident in question.
Resident's Dignity Compromised Due to Inadequate Colostomy Care
Penalty
Summary
The facility failed to ensure a dignified existence for Resident #4, who was found covered in feces due to a leaking colostomy bag. The incident occurred on 2/27/25, when Resident #4's family discovered her in this state, leading to significant distress and embarrassment for the resident. The resident had been admitted to the facility with a history of diverticulitis, hypertension, and depression, and had an ileostomy due to a perforated diverticulitis. Despite these conditions, the facility did not provide timely care to prevent the colostomy bag from leaking, resulting in feces covering the resident and her wound. Interviews and observations revealed that the staff did not respond promptly to Resident #4's needs. The resident reported that her colostomy bag frequently leaked during her first three days at the facility, and on 2/27/25, she lay in her own feces for approximately four hours. Family members confirmed the resident's account, noting that calls to the facility went unanswered and that staff were unresponsive to the resident's call light. The resident's family expressed their frustration and concern, highlighting the lack of timely intervention by the facility staff. Staff interviews indicated a lack of clarity regarding responsibilities for managing the resident's colostomy care. CNA B was unaware that she could empty the colostomy bag, and LVN C claimed to have emptied and changed the bag multiple times, yet was unaware of any ongoing issues. The Director of Nursing acknowledged the challenges in sealing the colostomy bag due to the resident's wound but admitted responsibility for ensuring staff were knowledgeable and provided timely care. The facility's failure to address these issues resulted in a significant breach of the resident's dignity and quality of life.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating resident needs and preferences. Resident #1, who had dementia, an amputation, and impulse disorder, was observed with his call light hanging on the privacy curtain at the foot of his bed, out of reach. He reported that this was a frequent issue, requiring him to holler for help. His care plan indicated he was a fall risk, and the intervention was to keep the call light within reach, which was not adhered to. Similarly, Resident #2, who had an overactive bladder, a femur fracture, and major depressive disorder, was found with his call light under the head of his bed on the floor, making it inaccessible. He was unaware of its location and stated he would have to yell for assistance. His care plan also noted a fall risk with an intervention to keep the call light within reach. Interviews with staff, including an LVN, CNA, and the DON, confirmed the expectation that call lights should be within reach, acknowledging the potential for falls or missed changes in condition if residents could not access their call lights.
Verbal Abuse Incident Involving Resident and CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA D. The incident occurred when the resident, who has severe cognitive impairment due to dementia and other medical conditions, was being assisted in the shower. During this time, CNA D accused the resident of lying and made derogatory comments, stating that the resident was a liar and that people did not want to deal with him. This interaction was overheard by the previous Director of Nursing (DON), who intervened and later reported the incident. The resident involved in the incident is an elderly individual with a history of dementia, Parkinson's disease, and insomnia, requiring moderate to maximal assistance with activities of daily living. The resident's cognitive impairment was evident, with a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Despite the resident's condition, the facility did not ensure that the resident was free from verbal abuse, as evidenced by the derogatory remarks made by CNA D during the shower assistance. The incident was documented in a Provider Investigation Report, which included statements from the resident, the previous DON, and CNA D. The report indicated that the resident did not appear to be in distress following the incident, and no physical injuries were observed. However, the verbal abuse was acknowledged by the previous DON, who deemed the comments made by CNA D as abusive. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from verbal abuse, which was not upheld in this case.
Inadequate Colostomy Care Leads to Resident Being Covered in Feces
Penalty
Summary
The facility failed to provide appropriate colostomy care for a resident, resulting in the resident being covered in feces due to a leaking colostomy bag. The resident, who had been admitted to the facility with a history of diverticulitis with perforation and abscess, hypertension, and depression, experienced multiple incidents of her colostomy bag leaking during her initial days at the facility. On one particular day, the resident's family found her covered in feces, which had leaked from her colostomy bag and had not been addressed by the staff for several hours. Interviews with staff and family members revealed that the resident's colostomy bag had been leaking frequently, and the staff had not been adequately trained or informed about their responsibilities in managing the colostomy care. The resident reported that her call light was not answered in a timely manner, leading to the colostomy bag becoming too full and leaking. The staff, including CNAs and LVNs, were unclear about their roles in emptying and changing the colostomy bag, resulting in the resident remaining in a soiled state for an extended period. The facility's Director of Nursing (DON) acknowledged that there was a lack of in-service training for staff regarding colostomy care upon the resident's admission. The DON admitted that the staff should have been knowledgeable about colostomy care from their training, but no specific in-service was conducted to ensure competency. The deficiency in care was further compounded by the physical challenges of sealing the colostomy bag due to the resident's surgical wound, which contributed to the frequent leaks.
Failure to Update Care Plan for Resident's Refusal of Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who had multiple medical conditions, including acute respiratory failure, cardiomyopathy, and severe cognitive impairment. The resident was noted to have a self-care deficit and was at risk for skin breakdown, but the care plan did not address his frequent refusals of care, including repositioning, medication intake, and other necessary interventions. Despite being marked as rejecting care in the MDS assessment, these refusals were not documented in the care plan, leaving staff without guidance on how to manage the resident's non-compliance effectively. Interviews with various staff members, including LVNs, the ADON, RN, CNA, and the MDS Coordinator, revealed a lack of clarity and responsibility regarding updating the care plan. Staff members acknowledged the resident's severe pain and refusal of care but did not ensure these issues were reflected in the care plan. The MDS Coordinator admitted that any refusals of care should have been documented if there was supporting evidence, but this was not done for the resident in question. The facility's policy required the interdisciplinary team to coordinate and update care plans based on assessments and changes in the resident's condition. However, the failure to revise the care plan for the resident's refusals of care placed him at risk of not receiving the necessary care and services. The DON and ADM confirmed that the care plan should have been updated to reflect the resident's needs and refusals, but this was not executed, leading to the deficiency noted in the report.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse, neglect, exploitation, or mistreatment of residents, specifically in the case of a resident who was roughly handled by a CNA during ADL care. The incident involved a CNA who did not suspend the alleged perpetrator immediately after the rough handling was reported. The CNA continued to work for seven more shifts before being suspended, and the facility did not report the abuse to the state agency within the required 24-hour timeframe. The resident involved was an elderly male with chronic respiratory failure, major depression, anemia, and congestive heart failure, who required moderate assistance for ADLs. The resident's family member provided video evidence showing the CNA handling the resident roughly, which upset the resident. Despite the family member reporting the incident to the ADON, the abuse was not reported to the abuse coordinator immediately, and the CNA continued to work with the resident and potentially other residents. Interviews revealed that the ADON was aware of the incident but delayed reporting it to the DON and Administrator, who were on vacation at the time. The DON was informed about the incident a week later and took action to suspend the CNA. The facility's failure to report the abuse immediately allowed the CNA to continue working, potentially putting other residents at risk. The facility's noncompliance was identified as PNC, with the Immediate Jeopardy beginning and ending within a specified timeframe.
Inadequate Supervision and Unsafe Practices in Resident Care
Penalty
Summary
The facility failed to ensure a safe environment for Resident #3 during incontinent care, resulting in a fall and injury. Resident #3, who had severe cognitive impairment and was a high fall risk, required extensive assistance from two staff members for bed mobility and personal hygiene. However, CNA D attempted to perform incontinent care alone, which led to Resident #3 rolling off the bed while reaching for something on her bedside table. This incident resulted in Resident #3 sustaining a laceration to her lip, requiring stitches, and being sent to the emergency room. In another incident, the facility failed to provide adequate supervision during mechanical lift transfers for Resident #5, who also had severe cognitive impairment and required two-person assistance for transfers. Despite this requirement, video evidence showed that CNA F transferred Resident #5 alone on multiple occasions. This practice was confirmed by interviews with staff, who reported that they often had to perform transfers alone due to staffing constraints, despite understanding the safety risks involved. The facility's policies and staff training were insufficient to prevent these incidents. Interviews with staff revealed a lack of adherence to care plans and inadequate staffing levels, which contributed to the unsafe practices. The DON and ADM were unaware of these issues, indicating a gap in oversight and communication within the facility. The absence of specific policies on repositioning during incontinent care and mechanical lift transfers further exacerbated the risk of accidents and injuries.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat two residents with respect and dignity, leading to deficiencies in their care. The first incident involved a resident who was denied assistance by a CNA when he requested to be repositioned in bed. The resident, who had a mild cognitive deficit and required moderate assistance for activities of daily living, was left in an uncomfortable position after the CNA refused to help due to her own physical limitations. The CNA admitted to not seeking help from other staff members and acknowledged that her actions were disrespectful. The second incident involved another resident who was subjected to an inappropriate comment by the previous Administrator. After the resident had been shaved, the Administrator made a remark comparing his appearance to that of a child molester, which embarrassed the resident. Although the resident initially laughed off the comment, he later expressed feeling embarrassed and did not want to discuss the incident further. The Administrator claimed the comment was made in jest, but the resident and other staff members reported the incident, leading to the Administrator's termination. Both incidents highlight a failure to uphold the residents' rights to dignity and respect, as outlined in the facility's policy. The actions of the CNA and the Administrator were reported by other staff members and family, indicating a breach of the residents' rights and a lack of adherence to the facility's standards for resident care.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in deficiencies in care. The first incident involved a resident who required moderate assistance with activities of daily living (ADLs) due to conditions such as chronic respiratory failure, major depression, anemia, and congestive heart failure. The resident, who had a mild cognitive deficit, was roughly handled by a CNA when being assisted into bed. Video evidence showed the CNA forcibly moving the resident's legs onto the bed, despite the resident's protests and expressions of pain. The CNA justified her actions by citing her own physical limitations and the resident's size, but her behavior was deemed inappropriate and led to her termination. The second incident involved another resident with dementia, heart failure, and limited mobility, who was verbally abused by a different CNA. The resident, who had moderate cognitive impairment, reported that the CNA used inappropriate language and engaged in a verbal altercation when the resident expressed dissatisfaction with being put to bed late. The CNA admitted to using a curse word and acknowledged that she should have handled the situation differently. The resident's care plan indicated a preference for not being cussed at, and the CNA's actions were inconsistent with the facility's policy on abuse and neglect. Both incidents highlight failures in the facility's ability to ensure a safe and respectful environment for its residents. The interactions between the CNAs and the residents were not only inappropriate but also violated the residents' rights to be free from abuse. The facility's policy mandates immediate reporting of abuse allegations, but the delay in addressing these incidents suggests a lapse in adherence to these procedures.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident within the required 2-hour timeframe. The incident involved a resident who was an elderly male with a history of chronic respiratory failure, major depression, anemia, and congestive heart failure. The resident required moderate assistance with activities of daily living (ADLs) and had a mild cognitive deficit. The incident was captured on video by the resident's family member, showing a certified nursing assistant (CNA) being rough and verbally harsh with the resident during care. The Assistant Director of Nursing (ADON) was informed of the incident by the resident's family member on the same day it occurred. However, the ADON did not report the incident to the facility's abuse coordinator or other authorities until eight days later. The delay was attributed to the ADON's uncertainty about whether the behavior constituted abuse and the absence of the Director of Nursing (DON) and Administrator, who were on vacation at the time. The facility's policy required immediate reporting of abuse allegations, but the ADON was unaware of the 2-hour reporting requirement. The DON was informed of the incident by the ADON after returning from vacation, and the abuse was reported to the Health and Human Services Commission (HHS) within one hour of notification. The facility's policy mandates that all allegations of abuse be reported immediately to the Administrator or their designee. The failure to report the abuse allegation in a timely manner could delay the investigation by the state agency, as noted by the Administrator. The facility's policy emphasizes a zero-tolerance approach to any form of abuse or mistreatment of residents.
Failure to Ensure Privacy During Resident Council Meetings
Penalty
Summary
The facility failed to allow for private Resident Council meetings and did not provide a private space for these meetings. During a confidential resident group interview, residents expressed their dissatisfaction with staff continuously interrupting their meetings held in the dining room. The interruptions were observed by the surveyor, who noted that staff entered the dining room through the back door, which led to the parking lot, despite being informed that a private meeting was in progress. The staff members claimed they were unaware of the meeting due to the absence of a sign indicating that a meeting was taking place. The Activity Director and the Ombudsman confirmed that staff interruptions were a recurring issue, and the Administrator acknowledged that the meetings should have been private and that staff behavior was inappropriate. The facility's policy on Resident Council meetings indicated that these meetings should be private and that staff could only attend if invited. However, the policy was not effectively implemented, as evidenced by the repeated interruptions by dietary staff. The lack of proper signage and the staff's disregard for the privacy of the meetings compromised the residents' ability to voice their concerns without interference. The Administrator admitted that alternative routes were available for staff to access the time clock and kitchen without disrupting the meetings, but these routes were not utilized.
Failure to Administer Ordered Pain Medication
Penalty
Summary
The facility failed to manage a resident's pain by not administering the ordered pain medication. Resident #144, who was admitted with multiple fractures and chronic pain, had an open-ended physician's order for a Lidocaine 5% topical patch to be applied daily. However, the medication was not administered from the date of admission until it was brought to the facility's attention by the resident and his family. Interviews with the resident, his family, and staff confirmed that the Lidocaine patch was not given, and the resident experienced ongoing pain as a result. The Director of Nursing acknowledged that the order for the Lidocaine patch was received from the hospital and should have been administered. The medication aide admitted to forgetting to give the patch due to being too busy. The Administrator also confirmed that it was the medication aide's responsibility to administer the patch and that the resident's pain could affect his mood and quality of life. The facility's policy on pain management indicated that staff should evaluate pain and provide medication as prescribed, which was not followed in this case.
Failure to Lock Medication Carts and Remove Expired Medications
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments for two of the four medication carts reviewed. During an observation, the 100-hall nurse medication cart was found unlocked with no staff present, containing various medications including Levetiracetam, Gabapentin, and Lisinopril. Similarly, the medication cart for the 300/400 hall was observed to be unlocked near the nurse's station, with medications such as Ondansetron and Eliquis accessible. Multiple staff members, including the ADM, RN, and LVN, acknowledged that medication carts should be locked when not in use, but the policy was not consistently followed, leading to potential risks of drug diversion and unauthorized access to medications by residents or others in the facility. Additionally, the facility failed to remove expired medications from the 100-hall nurse medication cart. Expired eye drops, Lumigan and Simbrinza, were found in the cart, and LVN E confirmed their expiration and removed them. Interviews with staff, including LVNs and MAs, revealed that they were responsible for checking and removing expired medications, but this was not consistently done. The DON and ADON also confirmed that expired medications should be removed and that administering expired medications could cause adverse side effects. The report highlights that the facility's staff, including nurses and MAs, were aware of the policies regarding locking medication carts and removing expired medications but failed to adhere to these policies consistently. This lack of compliance was observed during multiple instances, posing risks to resident safety and medication management within the facility.
Failure to Promote Resident Self-Determination
Penalty
Summary
The facility failed to promote resident self-determination through support of resident choice for two residents. Resident #32, who was cognitively intact and had a history of depression, was not assisted out of bed as often as she preferred. Despite her requests to be gotten out of bed once or twice a week, staff did not consistently honor her wishes, leading her to feel ignored and annoyed. Multiple staff members confirmed that Resident #32 was rarely gotten out of bed, and her refusals were not always documented as required. Resident #35, who had moderate cognitive impairment and a history of depression, was not provided with showers as per his request. He reported receiving only six showers since his admission and was often given bed baths instead. Additionally, Resident #35 preferred to be clean-shaven but was not shaved regularly, leading to a full beard of facial hair. Staff interviews revealed that the facility was understaffed, making it difficult to adhere to the residents' bathing schedules and personal care requests. Both residents expressed dissatisfaction with the care they received, which could negatively impact their psychological well-being. The facility's failure to honor these residents' preferences for personal care and mobility was acknowledged by the Director of Nursing and the Administrator, who admitted that the residents' wishes should have been respected and documented properly.
Failure to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for a resident with severe cognitive impairment and a history of depression. The wall behind the resident's bed had multiple areas of peeled paint, damaged sheetrock, and an old wallpaper cutout, which had been in this condition for months. The damage was reportedly caused by a hospice aide, the resident's family, and the bed's movement. Despite being aware of the issue, the Maintenance Supervisor had not yet repaired the wall, citing other priorities and the need to move the resident to another room for the repair. The family had been non-compliant in moving the resident's camera, which was necessary for the repair to proceed. The Maintenance Supervisor acknowledged the delay was his fault, and the Director of Nursing and other staff expressed that the wall should have been fixed sooner. Interviews with staff revealed that the issue had been reported to the Maintenance Supervisor long ago, but no work order was logged. The Maintenance Supervisor relied on verbal reports and had mentioned the issue in a stand-up meeting two weeks prior. The Administrator confirmed the need to move the resident for the repair and stated that the family had been asked for months to move the cameras. The facility's Homelike Environment policy indicated that resident rooms should be kept in good repair, but this was not adhered to in this case, leading to an unsafe and uncomfortable environment for the resident.
Failure to Provide Scheduled Bathing and Grooming Services
Penalty
Summary
The facility failed to ensure that two residents, who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Resident #21, a [AGE] year-old with severe cognitive impairment, did not receive scheduled baths/showers as per the facility's shower schedule. Despite being scheduled for showers on Monday, Wednesday, and Friday, the records indicated that Resident #21 only had six documented baths over a month. Interviews with staff revealed inconsistencies in the shower schedule and documentation, and the resident's representative expressed concerns about the resident's hygiene. Resident #35, a [AGE] year-old male with multiple diagnoses including traumatic amputation and severe kidney disease, also did not receive scheduled baths/showers and was not shaved as per his preference. The resident reported receiving only six showers since his admission and stated that he preferred to be clean-shaven. Observations confirmed that Resident #35 had a full beard, and staff interviews revealed that the resident's bathing and shaving needs were not consistently met due to staffing issues and time constraints. The facility's policies on comprehensive care planning, bathing, and hair care were not followed, leading to deficiencies in the care provided to these residents. Staff interviews indicated a lack of communication and documentation regarding residents' refusals and care needs. The DON and ADM acknowledged the issues and stated that residents should receive showers and shaves as per their schedules and requests, but these expectations were not met in practice.
Failure to Provide Scheduled Activities and Activity Calendar
Penalty
Summary
The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being of Resident #32. The resident, who was cognitively intact with a BIMS score of 14, expressed that she was not aware of any activities being provided and had not received an activities calendar. Despite the care plan indicating that the resident should be encouraged to participate in activities and provided with a schedule of events, these interventions were not consistently implemented. The resident reported feeling ignored and annoyed by the lack of engagement from the staff, and there were no documented refusals of activities in her records during the review period. Observations and interviews revealed that Resident #32 was often found in bed and not participating in group activities, such as arts and crafts or music sessions, which she stated she would have liked to attend if she had been informed. The Activity Director claimed to visit the resident daily and provide calendars, but this was contradicted by the resident's statements and the lack of documentation. The CNA and LVN interviewed also noted that the resident rarely got out of bed and did not attend activities, which could negatively impact her well-being. The facility's policy on one-on-one wellness visits was not followed, as there was no evidence of such activities being offered to Resident #32. The DON and Administrator acknowledged that the resident should have been provided with an activity calendar and offered activities, with any refusals documented. The failure to engage the resident in activities and provide her with the necessary information and encouragement could lead to feelings of isolation and depression, as noted by the staff interviewed.
Failure to Provide Catheter Securement Device
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to prevent urinary tract infections (UTI). Specifically, the facility did not provide an indwelling urinary catheter securement device for a resident, which is necessary to prevent catheter dislodgement, urethral damage, pain, and UTIs. The resident, who had severe cognitive impairment and a stage 4 pressure ulcer, required maximal to total assistance with most activities of daily living (ADLs) and had an indwelling urinary catheter. The care plan and physician orders indicated the need for a catheter securement device, but it was not in place during multiple observations by surveyors and staff interviews confirmed the oversight. During an observation, the resident's indwelling urinary catheter tubing was found pressed between her upper legs, causing red lines, and there was no securement device attached. The RN acknowledged noticing the missing securement device earlier but had not yet replaced it. The Director of Nursing (DON) confirmed that the securement device should have been replaced immediately or as soon as possible to prevent risks such as urethral trauma, dislodgement, infection, and skin breakdown. The facility's policy and CDC guidelines also emphasized the importance of securing indwelling catheters to prevent movement and urethral traction. Interviews with the RN and DON revealed that the securement device was likely missing since the previous day, and the RN had not had time to replace it. The DON stated that the nurses were responsible for ensuring the securement devices were in place and monitored each shift. The facility's administrator, who was not a nurse, also expected physician orders to be followed. The failure to replace the securement device promptly led to the deficiency noted in the report.
Failure to Ensure Safe and Sanitary Storage of Resident's Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident diagnosed with dementia, anxiety, and heart failure. During an observation, expired and decomposing meat products were found in the resident's refrigerator, including pickle and pimento loaf, salami, bologna, and smoked sausage. The expired foods were not removed even after the issue was brought to the attention of the housekeeping staff. The housekeeper admitted to not knowing who was responsible for cleaning out the personal refrigerators and stated that she would have thrown away the expired meat if instructed to do so. The Director of Nursing and the Administrator both acknowledged that anyone observing expired or decomposing food should have discarded it to prevent the risk of foodborne illness. The Administrator also mentioned that the resident's family should have helped in cleaning out the refrigerator, given the resident's cognitive impairments. Despite these acknowledgments, the expired food remained in the refrigerator, posing a potential health risk to the resident.
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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