Ignite Medical Resort Round Rock, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 16219 Ranch Road 620 North, Austin, Texas 78717
- CMS Provider Number
- 676440
- Inspections on file
- 39
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Ignite Medical Resort Round Rock, Llc during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, intact cognition, and a care plan requiring anti-Parkinsonian therapy did not consistently receive ordered Carbidopa-Levodopa doses at the specified times. Although the MAR showed doses as given, an internal audit revealed multiple late administrations outside the ordered schedule, including morning and afternoon doses. The NP had documented family concerns about late dosing and increased tremors and clarified the order to specific every-8-hour times. Facility leadership acknowledged that nurses and medication aides are responsible for timely administration, that Parkinson’s medications ordered for specific times must follow a strict time window, and that policy requires medications to be given at the correct time and frequency as ordered.
Two residents’ electronic clinical records were left visible on unattended computers on a unit, resulting in a failure to protect confidential information. In one case, a CNA left a charting station unlocked with a resident’s plan of care displayed after being called away to assist with care, despite prior HIPAA training and an expectation to lock the screen when stepping away. In another case, an RN left a nurse’s station computer unlocked with a resident’s MAR visible, acknowledging staff responsibility to secure screens. Leadership reported that staff receive HIPAA training at hire and annually and are expected to minimize or lock screens, but documentation of completed HIPAA in-services for the involved CNA and RN was not found, even though the facility’s Notice of Privacy Practices states that all staff are trained to protect health information.
A resident who required total assistance with ADLs was found to have two non-functioning call lights in her bathroom. The resident reported the issue, but it remained unresolved, and direct observation confirmed the deficiency. Staff interviews indicated that call lights should be checked and reported if not working, but the DON was unaware of the problem and there was no maintenance staff available at the time.
A resident with multiple medical conditions did not receive several scheduled doses of prescribed medications, including diuretics, anti-anxiety medication, antibiotics, and blood pressure medication. Staff interviews confirmed that medication administration was not documented in the EMAR as required by facility policy, and there was no record of reasons for the missed doses.
A resident with paraplegia was subjected to physical abuse by a CNA who attempted to take his vital signs against his will. The CNA used coercive tactics, such as withholding the resident's coffee and removing his call light and remote, to compel compliance. The resident reported feeling unsafe and described the CNA's behavior as aggressive and racially insensitive. Interviews confirmed the incident, highlighting a failure in the facility's duty to protect residents from abuse.
A facility failed to provide necessary wound care for three residents, leading to deficiencies in pressure ulcer management. A resident did not receive wound treatments for four days post-admission, missing additional treatments later. Two residents with wound vacs lacked orders for shift monitoring, risking inadequate wound management. Interviews with the CNO and WCN highlighted the facility's failure to meet expectations and adhere to its Skin Policy, despite prior in-service training.
A resident with stage 5 kidney failure experienced significant changes in condition, including inability to urinate, erratic behaviors, and multiple bruises, but the facility failed to notify the physician. The resident's care plan required monitoring and reporting of such changes, but these were not followed, leading to an Immediate Jeopardy situation.
A resident with stage 5 kidney failure experienced a deficiency in care when the facility failed to assess or notify the provider about her inability to urinate and erratic behaviors. Despite being on blood thinners and presenting with bruises, the facility did not follow the care plan or notify the MD of changes in mental status. The resident called 911 herself for hospital transfer, highlighting the facility's inaction and lack of timely intervention.
The facility failed to prevent pressure ulcers and conduct weekly skin assessments for four residents. A resident developed a Stage II pressure ulcer due to inadequate repositioning and prolonged exposure to soiled briefs. The facility's policy required weekly skin assessments, but these were not consistently documented for the residents involved, contributing to the deficiency.
A facility failed to maintain accurate medical records for two residents, leading to deficiencies in medication administration and wound care. One resident's anticoagulant medication was not properly documented, with errors in the electronic system indicating unsupervised self-administration without a physician's order. Another resident's wound care order was not transcribed correctly, resulting in the absence of a necessary dressing order. Staff interviews revealed a lack of clarity and communication regarding medication and treatment orders, contributing to the deficiencies.
A facility failed to implement proper infection control measures for a resident with a surgical wound by not placing them on Enhanced Barrier Precautions (EBP) and not ensuring PPE was available near resident rooms. Staff inconsistently used PPE, and the infection preventionist did not track adherence to protocols, leading to potential cross-contamination risks.
The facility failed to properly store, label, and sanitize food and equipment in its kitchen, leading to potential contamination risks. Foods were not sealed or dated correctly, and the industrial can opener was unsanitary. Additionally, staff did not consistently wear effective hair restraints, increasing the risk of food contamination.
The facility failed to provide an ongoing program of activities for its residents, as evidenced by the lack of a posted activity schedule and the cancellation of scheduled activities. Three residents, including those with mental health conditions and physical impairments, were unaware of available activities and expressed feelings of frustration and isolation. The Activity Director acknowledged the deficiencies, citing staffing shortages and scheduling conflicts as reasons for the failure to adhere to the facility's Activity Policy.
A resident with dementia and diabetes, requiring assistance with personal hygiene, did not receive necessary nail care, resulting in excessively long and jagged nails. Despite expressing a desire for nail trimming, the facility failed to document or provide the service, highlighting a deficiency in grooming care. Staff interviews revealed inadequate documentation and communication regarding the resident's grooming needs.
Two residents with mobility and cognitive impairments were directed to smoke in an unsafe area without supervision, leading to a deficiency. Both residents, identified as unsafe smokers, were observed smoking in a roadway, expressing concerns about safety and inconsistent smoking rules. The facility failed to provide adequate supervision and a safe smoking area, resulting in a deficiency.
The facility failed to enforce its no-smoking policy for two residents, who were observed smoking outside despite the facility's non-smoking designation. Both residents retained their cigarettes and lighters, and were not assessed for smoking safety. Staff inconsistently enforced the policy, leading to a deficiency in maintaining a safe environment.
A resident with a history of urine retention and an indwelling catheter was not monitored for urine output for three days, leading to a urinary tract infection and hospitalization. Despite the care plan requiring monitoring for signs of UTIs and dehydration, there were no specific orders for urine output monitoring. Interviews revealed the importance of such monitoring, especially for residents with Foley catheters, to prevent complications. The facility's failure to adhere to its policies resulted in the resident's condition worsening.
The facility failed to document nursing notes in the EMRs of three residents at the time of their discharge, contrary to its discharge policy. This oversight involved residents with conditions such as diabetes, urinary tract infections, and muscle weakness. The VPCS confirmed that nurses are expected to document changes in condition, new orders, hospital transfers, or discharges to ensure continuity of care.
A resident in an LTC facility was exposed to potential infection risks when CNA A and LVN B failed to follow proper infection control protocols during pericare. CNA A used soiled gloves to handle clean items without changing them or performing hand hygiene, while LVN B did not notice or correct the breach. Both staff members had not participated in recent infection control training, contributing to the deficiency.
A resident with serious infections did not receive scheduled doses of ceftriaxone due to a failure in communication and protocol adherence by the facility staff. Despite pharmacy follow-ups, the staff did not inform the NP or administration about the missing medication, leading to the resident's hospitalization.
A resident with serious infections did not receive scheduled doses of ceftriaxone due to staff failing to follow up with the pharmacy, communicate with the NP, or notify administration. This resulted in the resident being sent to the hospital for consistent antibiotic treatment.
A resident with serious infections was not administered ceftriaxone as scheduled due to the facility's failure to ensure timely medication delivery and communication with medical staff. This resulted in the resident being sent to the hospital for consistent treatment. Staff interviews revealed lapses in following protocol for medication administration and communication.
Failure to Administer Parkinson’s Medication at Ordered Times
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when nursing staff did not administer a resident’s Parkinson’s medication at the physician-ordered times. The resident had an order for Carbidopa-Levodopa oral disintegrating tablets, 25-100 mg, 1.5 tablets by mouth every 8 hours for Parkinson’s disease, with instructions to give at the scheduled time and to notify the provider if unable to do so. The Medication Administration Record for the month showed the doses as given but did not document the specific administration times. The facility’s Medication Administration Audit Report, however, showed multiple instances where the medication was administered later than the scheduled times. The audit report documented that one morning dose scheduled for 6:00 a.m. was given at 8:33 a.m., and several afternoon doses scheduled for 2:00 p.m. were given between 3:04 p.m. and 4:00 p.m. These late administrations occurred on multiple days. Prior to these findings, the nurse practitioner had documented that the resident’s family voiced concerns that the Parkinson’s medication was being given later than scheduled and that the resident had increased tremors. In response to these concerns, the NP discussed the issue with nursing and adjusted the order to specify administration every 8 hours at specific times. The resident was an older male with Parkinson’s disease with fluctuations, hypertension, and a traumatic subarachnoid hemorrhage, and had an intact BIMS score of 15. His comprehensive care plan included anti-Parkinsonian therapy with interventions to administer medications as ordered and to monitor and document side effects and effectiveness every shift. Interviews with the administrator and the vice president of clinical operations confirmed that nurses and medication aides were responsible for timely medication administration, that certain medications such as Parkinson’s medications ordered for specific times should follow a one-hour before and after window, and that late administration could affect the conditions being treated. The facility’s Medication Pass Policy stated that medications must be administered at the correct time and frequency as ordered, including the resident’s right to timely and appropriate medication administration.
Failure to Protect Electronic Health Information from Unauthorized Viewing
Penalty
Summary
The deficiency involves the facility’s failure to maintain secure and confidential clinical records for two residents on the Kindle Unit. On 1/28/2026 at 9:09 a.m., a surveyor observed the CNA charting station computer on the Kindle Unit with the screen open and unlocked, displaying Resident #2’s personal plan of care information. The screen was visible to unauthorized individuals, including visitors or other residents, although no unauthorized individuals were present at that moment. Resident #2’s face sheet showed he was a 95-year-old male with diagnoses including acute posthemorrhagic anemia, acute kidney failure, and type 2 diabetes mellitus. During an interview later that day at 12:15 p.m., the CNA stated she had received HIPAA in-service training a few months earlier, which included instructions not to discuss residents’ private clinical information with unauthorized individuals and to lock the computer screen when stepping away. She acknowledged that everyone who worked with charting computers was responsible for closing and locking them when not in attendance. She explained that she had been called by another staff member to help with resident care and forgot to close the computer screen, and confirmed she was responsible for shutting down and locking the charting computer when stepping away. She stated that leaving the screen unlocked with clinical information displayed could be harmful because anybody could see it. A second incident was observed on 1/28/2026 at 10:00 a.m., when the RN’s nurse’s station computer on the Kindle Unit was found open and unlocked, displaying Resident #1’s medication administration record, visible to unauthorized individuals, including visitors or other residents, though no unauthorized individuals were present at that time. Resident #1’s face sheet showed she was a 66-year-old female with diagnoses including type 2 diabetes mellitus, myopathy, and polyneuropathy. In an interview at 10:05 a.m., the RN stated that staff working with residents’ personal information were responsible for shutting down charting computer screens when leaving and that he had received HIPAA training several months earlier. He acknowledged that leaving a computer screen without locking it could lead to exposing residents’ private medical information and violating their privacy. The Administrator and Vice President of Clinical Operations both stated in interviews that staff are trained at hire and annually on HIPAA and are responsible for minimizing or locking screens when stepping away, but record review did not show documented HIPAA in-services completed by the CNA and RN before these incidents, despite the facility’s Notice of Privacy Practices stating that all staff are trained at employment, annually, and as needed.
Inoperable Call Lights in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident's bathroom was found to have two call lights that were not functioning. The resident, who required total assistance with activities of daily living (ADLs) such as toileting, personal hygiene, transfer, and bathing due to conditions including low back pain, right leg pain, and osteoporosis, reported that the call lights in her bathroom were not working. She stated that she had informed someone about the issue, but could not recall when or to whom. Direct observation confirmed that pulling the call light strings did not activate the system. Interviews with staff revealed that call lights were supposed to be checked randomly and that non-functioning call lights should be reported to management. The DON was unaware of the issue and stated that there was currently no maintenance person on staff, though one had been hired to start in a week. Facility policy required that call light systems be available for resident communication and that residents be evaluated for their ability to use them, with alternatives provided if necessary. The failure to maintain operable call lights in the resident's bathroom constituted the deficiency.
Failure to Ensure Accurate Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, the resident did not receive multiple prescribed medications, including Furosemide, Spironolactone, Alprazolam, Metronidazole, and Midodrine HCl, on several scheduled occasions. Medication Administration Records (MAR) showed missed doses, and there was no documentation to indicate whether the medications were administered or the reasons for omission. The resident involved was an adult female with diagnoses including spontaneous bacterial peritonitis, streptococcal infection, and generalized anxiety disorder. Her care plan included the administration of anti-anxiety medications as ordered by her physician, but there was no care plan addressing medication refusal or missed doses. The resident's cognitive status was intact, as indicated by a BIMS score of 15 on her admission MDS. Interviews with nursing staff and medication aides revealed that it was the responsibility of the person administering medications to document administration in the electronic MAR (EMAR). Staff confirmed that if administration was not documented, it could not be confirmed that the medication was given. Facility policy required that all medication administration be recorded in the EMAR, and if a medication was not administered, the reason should be documented and the physician or nurse practitioner notified. However, in this case, there were blanks in the EMAR with no documentation or explanation for the missed doses.
CNA's Coercive Actions Lead to Abuse Deficiency
Penalty
Summary
The facility failed to ensure that all residents were free from physical abuse, as evidenced by an incident involving a CNA and a resident. The resident, who was admitted with conditions including paraplegia and chronic pain, was subjected to forceful actions by the CNA. The incident occurred when the CNA attempted to take the resident's vital signs against his will. Despite the resident's refusal, the CNA used force to lay the resident on his back and took away his call light and television remote, which were out of his reach due to his physical limitations. The resident reported feeling that the CNA's actions were abusive, and he expressed that he did not want his vital signs taken. The CNA, however, insisted and used coercive tactics, such as withholding the resident's coffee and removing his call light and remote, to compel compliance. The resident described the CNA's behavior as aggressive and reported that she made a racially insensitive remark during the incident. The resident was unable to physically resist due to his paraplegia, which left him vulnerable to the CNA's actions. Interviews with facility staff and the resident confirmed the details of the incident. The CNA admitted to taking the resident's call light and remote, believing they were engaging in playful behavior. However, the resident did not perceive the interaction as playful and felt unsafe. The facility's policy on abuse and neglect clearly defines such actions as abusive, particularly when a resident's autonomy and rights are disregarded. The incident highlights a failure in the facility's duty to protect residents from abuse and ensure their rights are respected.
Deficiencies in Pressure Ulcer Management and Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatments for three residents, leading to deficiencies in pressure ulcer management. Resident #1, a female with multiple health conditions including type II diabetes and chronic kidney disease, was admitted with several pressure ulcers. Despite having physician orders for wound care, she did not receive any treatments for four days after admission and missed additional treatments on specific dates in December 2024 and January 2025. Resident #2, a male with paraplegia and stage IV pressure ulcers, had a wound vac in place but lacked orders for monitoring it every shift. Although his wound vac was observed to be functioning correctly, the absence of monitoring orders could lead to inadequate wound management. Similarly, Resident #3, also with paraplegia and unspecified staged pressure ulcers, had a wound vac without shift monitoring orders, which could compromise the effectiveness of the treatment. Interviews with the Chief Nursing Officer (CNO) and the Wound Care Nurse (WCN) revealed that the facility's practice did not align with their expectations or the facility's Skin Policy and Procedure. The CNO and WCN emphasized the importance of timely wound treatment orders and regular monitoring of wound vacs to prevent worsening of wounds and ensure infection control. Despite an in-service conducted on skin assessments, the facility did not adhere to its policy, resulting in the identified deficiencies.
Failure to Notify Physician of Significant Changes in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status. This deficiency was identified for a resident with a diagnosis of stage 5 kidney failure, who complained of not being able to urinate. Despite the resident's complaint, there was no documentation that the medical provider was notified of this change in urinary status. Additionally, the facility did not notify the medical provider when the resident, who had a BIMS score indicating intact cognition, began exhibiting erratic behaviors, changes in mental status, confusion, and agitation. The resident's comprehensive care plan included interventions for monitoring and reporting changes in mental status, but these were not followed, and the provider was not informed of the resident's altered behavior. Furthermore, the facility failed to notify the medical provider or abuse coordinator when the resident presented with multiple bruises on her abdomen, back, legs, arms, and forehead. The resident was on anticoagulant therapy, which increased the risk of bleeding and bruising, yet the facility did not report these findings to the physician. The lack of timely notification and documentation of these significant changes in the resident's condition led to the identification of an Immediate Jeopardy situation.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to a resident with stage 5 kidney failure, resulting in a deficiency. The resident complained of not being able to urinate, but the facility did not assess the resident or notify the provider. Additionally, the resident, who was on blood thinners, presented with bruises all over her body and exhibited erratic behaviors such as throwing herself on the floor and hitting herself on the head. Despite these significant changes in condition, the facility did not assess the resident, notify the provider, or the abuse coordinator. The facility also failed to follow the care plan and notify the medical doctor of changes in the resident's mental status, confusion, and agitation. The resident's care plan included interventions for depressive symptoms, risk for falls, potential alteration in nutrition and hydration, and reactions to anti-anxiety and anticoagulant medications. However, the care plan did not address the resident's kidney disease. The resident's behaviors, such as yelling, clogging toilets, and breaking items, were not documented or reported to the provider, and the facility did not investigate the cause of these behaviors. Furthermore, the facility failed to assist the resident in transferring to the hospital. The resident called 911 herself and waited 27 minutes on the phone until EMS arrived. The facility's inaction and lack of timely intervention placed the resident at risk for not receiving necessary care, leading to a decline in health and hospitalization. The deficiency was identified as an Immediate Jeopardy, indicating a serious threat to the resident's health and safety.
Failure to Prevent Pressure Ulcers and Conduct Weekly Skin Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for four residents. Resident #3 developed a Stage II pressure ulcer on the right buttock, which was identified after discharge. The resident's care plan indicated a risk for skin integrity issues, and interventions included applying barrier cream and assisting with repositioning every 2-3 hours. However, interviews with the resident's family and staff revealed that the resident was left in soiled briefs for extended periods and was not repositioned frequently, contributing to the development of the pressure ulcer. The facility also failed to complete weekly skin assessments for Residents #1, #2, #3, and #4, as required by their policy. Resident #1 had redness on the sacrum upon admission, and the care plan included interventions to prevent skin breakdown. However, the weekly skin evaluations were not documented as completed, despite being signed off in the medication/treatment administration records. Similarly, Resident #2's care plan included skin checks and repositioning, but the weekly skin evaluations were not documented, indicating a lack of adherence to the facility's policy. Interviews with facility staff, including the ACNO and LVN C, confirmed that skin assessments were supposed to be conducted weekly, but this was not consistently done. The facility's policy emphasized the importance of comprehensive skin assessments and treatments to prevent pressure injuries, yet the lack of documentation and adherence to the policy contributed to the deficiencies observed. The failure to conduct regular skin assessments and implement care plan interventions placed residents at risk for developing pressure ulcers.
Deficiencies in Medication Administration and Wound Care Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in medication administration and wound care. For one resident, the facility did not accurately document the administration of an anticoagulant medication, Apixaban, from late October to early November. The resident's Medication Administration Record (MAR) showed unknown administration status for several days, and there was no physician's order for self-administration, despite the MAR indicating unsupervised self-administration. An LVN admitted to administering the medication but noted that the electronic system incorrectly recorded the administration status due to a selection error. Another resident's wound care order was not transcribed correctly, resulting in the absence of a necessary dressing order on the Treatment Administration Record (TAR). The resident had a surgical wound and required a hydrocolloid dressing for denuded skin, but the order was not reflected in the TAR. The resident reported having to request staff assistance for dressing changes due to excessive drainage from the wound. The VPCO acknowledged the issue but was unable to resolve the transcription error in the electronic system. Interviews with facility staff revealed a lack of clarity and communication regarding medication and treatment orders. The VPCO and LVN both indicated that incorrect orders should be clarified with the provider, but this was not consistently done. The facility's policies on self-administration of medications and physician orders were not followed, contributing to the deficiencies in record-keeping and patient care.
Inadequate Infection Control and PPE Availability
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, which resulted in a deficiency related to the care of a resident with a surgical wound. The resident, a female with a history of a hip fracture and other medical conditions, was admitted to the facility with a surgical wound that required care. Despite the presence of this wound, the facility did not place the resident on Enhanced Barrier Precautions (EBP) as required, which could have helped prevent the transmission of infections. Observations and interviews revealed that personal protective equipment (PPE) was not readily available near or outside the rooms of residents on EBP, including the resident with the surgical wound. Staff members, including CNAs and LVNs, provided care without consistently using gowns, and PPE was stored at a distance from the resident's room, making it less accessible. The facility's infection preventionist and other staff members acknowledged the lack of adherence to EBP protocols and the potential for cross-contamination due to improper PPE usage. The facility's policies on infection control and EBP were not effectively implemented, as evidenced by the lack of PPE availability and inconsistent staff training. Interviews with staff indicated confusion and varying levels of understanding regarding the use of PPE and EBP protocols. The infection preventionist admitted to not tracking observations of hand hygiene or PPE usage, further contributing to the deficiency. The facility's approach to maintaining a home-like environment by not placing PPE carts near resident rooms also hindered the effective implementation of infection control measures.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and distribution in its only kitchen, as observed during a survey. Foods in the kitchen's freezer, refrigerator, activity room snack bar, and walk-in cooler were not properly sealed, labeled, or dated. Specific items such as frozen tater tots, spicy black bean hamburger patties, and various containers of food lacked labels indicating the date opened or use-by date. Additionally, some items were left unsealed and exposed to air, increasing the risk of contamination. The facility's labeling system was designed to prevent food from being held too long and becoming unsafe, but it was not effectively implemented. The kitchen's industrial can opener was found to be unsanitary, with a black sticky substance present on its components. The dishwasher could not recall the last time the can opener was cleaned, and there was no posted cleaning schedule for kitchen equipment. This lack of sanitation could lead to contamination of food items, particularly those not heated to temperatures sufficient to kill pathogens. The facility's policy required equipment to be washed and rinsed after each use, but this was not being followed. Furthermore, the kitchen staff did not consistently wear effective hair restraints. The HC was observed preparing food without proper coverage of his mustache, despite the facility's policy requiring hair restraints to cover all head and facial hair. This oversight could result in hair contaminating the food. The facility's Infection Prevention & Control for Food Service Policy emphasized the importance of wearing hair restraints and maintaining sanitary conditions to prevent foodborne illnesses, but these standards were not met during the survey.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the needs and preferences of its residents, as evidenced by the lack of a posted activity schedule and the cancellation of scheduled activities. Observations on multiple days revealed that the facility did not display a resident activity schedule in prominent locations such as the entrance, hallways, or information boards. Additionally, activities that were scheduled, such as crafts and painting, were not held as planned, leaving residents unaware of available activities. Three residents were specifically affected by these deficiencies. One resident, diagnosed with anxiety, bipolar disorder, and major depression, expressed frustration and isolation due to not receiving an activity calendar or being informed of activities. Another resident, with acute respiratory failure and an acquired absence of the left leg, was not aware of any activities and felt aggravated by the lack of information. A third resident, diagnosed with depression and an anxiety disorder, was disappointed to learn that activities were supposed to be provided but had not been informed or reminded by staff. The facility's Activity Director (AD) acknowledged the lack of posted activity calendars and the failure to provide residents with copies. The AD, who had been in the position for eight months without formal training or certification, cited staffing shortages and scheduling conflicts as reasons for the cancellation of activities. The facility's Activity Policy required that group activities be offered to all residents and that a calendar of activities be made available upon admission and monthly thereafter, which was not adhered to.
Failure to Provide Necessary Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary grooming services, specifically nail care, for a resident diagnosed with dementia and diabetes mellitus type 2, who required assistance with personal hygiene. The resident, who had moderate cognitive impairment and an amputation of the left index finger, was observed with excessively long and jagged fingernails on multiple occasions. Despite the resident's need for assistance, the facility did not ensure that her nails were trimmed, which could have led to potential risks such as scratches, infections, or lowered self-esteem. Interviews and record reviews revealed that the facility's staff did not document the resident's need for nail care or any refusal of such care. The resident expressed a desire for her nails to be trimmed, contradicting a staff member's claim that she had refused the service. The facility's documentation system, PCC, did not allow for detailed notes on shower observations, limiting staff to simple yes or no responses regarding task completion. This lack of documentation and communication contributed to the oversight in providing necessary nail care. The facility's policy required staff to assess grooming needs and document observations, but there was no record of shower or skin observations for the resident. Staff interviews indicated that the responsibility for documenting these observations was unclear, and the facility's safeguards, such as regular rounds and paper shower observation sheets, were not effectively implemented. This deficiency highlights a failure in the facility's processes to ensure residents receive the necessary assistance with activities of daily living, particularly in maintaining personal hygiene.
Inadequate Supervision for Smoking Residents
Penalty
Summary
The facility failed to ensure adequate supervision and safety for two residents who were directed to smoke outside in the roadway without supervision. Both residents, one with moderate cognitive impairment and the other with intact cognition, were observed smoking outside the facility without staff supervision. The residents were instructed by facility staff to smoke in areas off the property, which were not safe due to the presence of a roadway and uneven ground. Resident #37, a male with a history of falls and moderate cognitive impairment, was observed smoking in the road without supervision. He had not been assessed for smoking safety and expressed concerns about the inconsistency of smoking rules and the safety of the designated smoking area. Similarly, Resident #42, who had a history of hemiplegia and repeated falls, was also observed smoking in the same unsafe area. He reported difficulty maneuvering his wheelchair to the designated spot due to his physical limitations and expressed fear of being hit by a car. Both residents were non-compliant with the facility's no-smoking policy and had refused smoking cessation alternatives. Despite being identified as unsafe smokers, they were allowed to smoke in unauthorized areas without adequate supervision, posing a risk to their safety. The facility's failure to provide a safe and supervised smoking area for these residents led to the deficiency identified in the report.
Failure to Enforce No-Smoking Policy
Penalty
Summary
The facility failed to establish and enforce a no-smoking policy for two residents, leading to a deficiency in maintaining a safe environment. Both residents were observed smoking outside the facility, despite the facility's designation as a non-smoking environment. The residents were not assessed for smoking safety, and they retained possession of their cigarettes and lighters, which were not secured by the facility staff. Resident #37, a male with moderate cognitive impairment and mobility issues, was observed smoking outside the facility. His care plan indicated non-compliance with the no-smoking policy, and he refused smoking cessation alternatives. Similarly, Resident #42, who had intact cognition but suffered from physical impairments due to a stroke, was also observed smoking outside. Both residents were instructed by staff to smoke off the property, but they were not consistently monitored or assessed for safety risks associated with smoking. Interviews with facility staff revealed inconsistencies in the enforcement of the smoking policy. The General Manager and other staff members acknowledged the facility's non-smoking policy but admitted to taking residents off-site to smoke due to non-compliance. The facility's policy required residents to surrender tobacco products, but this was not enforced, leading to the residents retaining their smoking materials. The lack of consistent policy enforcement and safety assessments for smoking residents contributed to the deficiency.
Failure to Monitor Urine Output Leads to Resident Hospitalization
Penalty
Summary
The facility failed to provide appropriate care for a resident with a history of urine retention and an indwelling catheter, leading to a urinary tract infection and subsequent hospitalization. The resident, who had been admitted with diagnoses including urinary tract infection, severe sepsis, and neuromuscular dysfunction of the bladder, was not monitored for urine output for three days. This lack of monitoring resulted in the removal of 700 CCs of urine via an intermittent catheter and the resident being sent to the hospital due to swelling in the groin, a non-draining Foley catheter, and cloudy urine with clots of pus. The resident's care plan included monitoring for signs and symptoms of urinary tract infections and dehydration, but there were no specific orders for monitoring urine output. Interviews with the nurse practitioner and medical doctor revealed that monitoring urine output was crucial for residents with Foley catheters, especially those with a history of urine retention, to prevent complications such as UTIs and bladder rupture. The facility's policy required physician orders for catheter care, including monitoring output, but these were not in place for the resident. The facility's failure to monitor and document the resident's urine output as per the care plan and policy led to the resident's condition worsening, resulting in hospitalization. The lack of specific orders for Foley catheter care and urine output monitoring contributed to the oversight in the resident's care, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Failure to Document Resident Discharges in EMRs
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records of three residents who were discharged. Specifically, nursing notes were not documented in the electronic medical records (EMRs) of these residents at the time of their discharge. This lack of documentation was identified during a review of the residents' records, which showed that the last nursing notes were recorded days before their discharge, with no mention of the discharge itself. The facility's discharge policy requires documentation of the resident's condition, notification of transfer, destination, mode of transportation, and disposition of belongings and medications, none of which were recorded for these residents. The residents involved had various medical conditions, including adult failure to thrive, type II diabetes, urinary tract infections, muscle weakness, depression, anxiety disorder, and fibromyalgia. The facility's Vice President of Clinical Services (VPCS) confirmed during an interview that nurses are expected to document any changes in condition, new orders, hospital transfers, or discharges in the progress notes to ensure continuity of care. The failure to document these discharges could lead to errors in care and treatment, as it leaves nursing staff without critical information about the residents' status and discharge plans.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A and LVN B during the provision of pericare to a resident. During the procedure, CNA A used soiled gloves to handle clean items, including a new brief and a packet of wet wipes, without changing gloves or performing hand hygiene. This breach in protocol was observed when CNA A removed a soiled brief and wiped the resident's perineal area, then proceeded to handle clean items with the same gloves. The resident, who had multiple medical conditions including fractures, alcoholic cirrhosis, and hypertension, was at risk of infection due to this lapse in infection control. Interviews with CNA A and LVN B revealed that both staff members failed to follow proper hand hygiene and glove-changing protocols. CNA A admitted to forgetting to wash her hands and change gloves, while LVN B acknowledged not noticing the breach and failing to correct it. The interim CNO confirmed the importance of adhering to infection control protocols and recognized the breach. A review of in-service records indicated that both CNA A and LVN B had not participated in recent training on enhanced barrier precautions, which may have contributed to their non-compliance with the facility's infection control policy.
Failure to Administer Antibiotics and Notify Physician
Penalty
Summary
The facility failed to inform a resident's physician or nurse practitioner when there was a significant need to alter treatment, specifically regarding the administration of scheduled medications. The resident, who had been admitted with diagnoses including encephalitis, encephalomyelitis, and bacteremia, was not given ceftriaxone, an antibiotic, for four scheduled doses over a period of three days. Despite staff following up with the pharmacy, they did not communicate the lack of antibiotics to the nurse practitioner or administration, resulting in the resident being sent to the hospital for consistent antibiotic treatment. Interviews with staff revealed that the antibiotics were not available upon the resident's arrival, and although the pharmacy was contacted, the medication was not delivered in a timely manner. Staff members admitted to not following the proper protocol, which included checking the emergency kit, contacting the pharmacy, and notifying the nurse practitioner or director of nursing about the missing medication. This oversight led to the resident missing several doses of the critical antibiotic, which was essential for treating her infection. The nurse practitioner was only informed of the missed doses on the day the resident was sent to the emergency room. The lack of communication and failure to follow established procedures for medication administration and notification resulted in the resident being at risk of serious harm, as the antibiotics were crucial for her recovery and preventing further infection.
Removal Plan
- Education was given to DON and GM by Chief Clinical Officer.
- Inservice will be completed by all fulltime staff and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA).
- Training for all new hires, PRN and part time employees will be completed prior to start of shift.
- Post test will be conducted after Inservice.
- Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider.
- Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs.
- Contact pharmacy immediately. Nurses & CMAs.
- Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs.
- Notify physician to request for alternative orders. ONLY for nurses.
- Document and carry out provider's instructions immediately. ONLY for nurses.
- Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - DON Contact information is posted in med room.
- Contact GM Contact information is posted in Med Room.
- Contact assigned provider ONLY for nurses.
- Contents of medication dispensing machine and IV E-kits - see Attachment A.
- Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message.
- Inservice will be required to be completed prior to start of shift.
- There will be post test given and graded by CNO and/or GM.
- Nursing staff initiated a MAR-to-Cart audit of all in-house residents to ensure medications are available and to order/reorder medications that are not available in the medication carts.
- The medication lists of all new admissions will be matched with actual medications by DON and or designee and will be ongoing process.
- Medications should be available by next delivery period and/or within 24 hours of order entry.
- If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine.
- Then follow regular delivery for the next dose.
- If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery.
- List of medications available on the medication dispensing machine was posted by DON in the medication rooms.
- DON and/or designee will complete a daily audit of medications for new admissions.
- Then will be reduced to weekly x 2 weeks.
- Then move to random new admit medication audits.
- If there is missing medication, DON and/or designee will ensure that the notification tree was activated and will be ongoing process.
- Findings will be discussed weekly between GM, DON and/or designee and VP of clinical operations.
- There was an ADHOC QAPI meeting held with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called.
- Findings will also be presented during monthly QAPI meeting x3 months.
Failure to Administer Antibiotics Leads to Hospitalization
Penalty
Summary
The facility failed to provide pharmaceutical services, including the accurate acquiring and administering of medications, for a resident who was prescribed ceftriaxone, an antibiotic used to treat bacterial infections. The resident did not receive the scheduled doses of ceftriaxone on multiple occasions, specifically missing four doses over a period of three days. This failure was due to the staff not following up with the pharmacy for the delivery of the medication, not communicating the lack of antibiotics to the nurse practitioner (NP), and not informing the administration about the missed doses. The resident, who had been admitted with diagnoses including encephalitis, encephalomyelitis, and bacteremia, was at risk due to the missed antibiotic doses. The resident's medical records indicated that the ceftriaxone was pending delivery from the pharmacy, and the staff failed to take appropriate actions to ensure the medication was administered. As a result, the resident was sent to the hospital to receive consistent antibiotic treatment to address the bacteremia and ventriculitis. Interviews with the nursing staff revealed that there was a lack of communication and follow-up regarding the missing medication. The staff admitted to not checking the emergency kit for the medication, not contacting the pharmacy, and not notifying the NP or administration about the issue. This lack of action and communication led to the resident not receiving the necessary treatment, which could have resulted in serious health consequences.
Removal Plan
- Education was given to DON and GM by Chief Clinical Officer.
- Inservice will be completed by all fulltime staff and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA).
- Training for all new hires, PRN and part time employees will be completed prior to start of shift.
- Post test will be conducted after Inservice.
- Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider.
- Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs.
- Contact pharmacy immediately. Nurses & CMAs.
- Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs.
- Notify physician to request for alternative orders. ONLY for nurses.
- Document and carry out provider's instructions immediately. ONLY for nurses.
- Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - DON Contact information is posted in med room.
- Contact GM Contact information is posted in Med Room.
- Contact assigned provider ONLY for nurses.
- Contents of medication dispensing machine and IV E-kits - see Attachment A.
- Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message.
- Inservice will be required to be completed prior to start of shift.
- There will be post test given and graded by CNO and/or GM.
- Nursing staff initiated a MAR-to-Cart audit of all in-house residents to ensure medications are available and to order/reorder medications that are not available in the medication carts.
- The medication lists of all new admissions will be matched with actual medications by DON and or designee and will be ongoing process.
- Medications should be available by next delivery period and/or within 24 hours of order entry.
- If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine.
- Then follow regular delivery for the next dose.
- If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery.
- List of medications available on the medication dispensing machine was posted by DON in the medication rooms.
- DON and/or designee will complete a daily audit of medications for new admissions.
- Then will be reduced to weekly x 2 weeks.
- Then move to random new admit medication audits.
- If there is missing medication, DON and/or designee will ensure that the notification tree was activated and will be ongoing process.
- Findings will be discussed weekly between GM, DON and/or designee and VP of clinical operations.
- There was an ADHOC QAPI meeting held with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called.
- Findings will also be presented during monthly QAPI meeting x3 months.
Failure to Administer Antibiotic Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of ceftriaxone, an antibiotic used to treat bacterial infections. The resident, who had been admitted with diagnoses including encephalitis, encephalomyelitis, and bacteremia, was not given ceftriaxone for a total of four times over a period of three days. This lapse in medication administration led to the resident being sent to the hospital for consistent antibiotic treatment to address bacteremia and ventriculitis. Interviews and record reviews revealed that the staff did not follow up adequately with the pharmacy to ensure the timely delivery of the medication. Additionally, there was a lack of communication with the nurse practitioner (NP) and administration regarding the missed doses. The resident's medication administration record (MAR) indicated that the ceftriaxone was pending pharmacy delivery, and the staff failed to take necessary actions to rectify the situation, such as checking the emergency kit or contacting the pharmacy and medical providers for alternatives. The deficiency was identified as an immediate jeopardy (IJ) situation, highlighting the potential risk to residents of not receiving their scheduled medications accurately and timely. Interviews with various staff members, including registered nurses (RNs) and licensed vocational nurses (LVNs), confirmed the oversight and acknowledged the failure to adhere to the facility's procedures for medication ordering and administration. The staff admitted to not following the protocol due to assumptions about the medication's arrival and the busy nature of their shifts.
Removal Plan
- Education was given to DON and GM by Chief Clinical Officer.
- Inservice will be completed by all fulltime staff and be conducted by director of nursing (DON), general manager (GM) to all Fulltime, part time, PRN nurses and certified medication aides (CMA).
- Training for all new hires, PRN and part time employees will be completed prior to start of shift.
- Post test will be conducted after Inservice.
- Proper ordering/reordering medications process - will review the pharmacy policy section 3.2 entitled Medication Ordering and Receiving From Pharmacy Provider.
- Proper Protocol for all Facility Nurses and medication aides for bullet points 1,2, and 3. when medication is unavailable - Check Medication expensing machine and IV E-kit immediately. Nurses & CMAs.
- Contact pharmacy immediately. Nurses & CMAs.
- Notify DON and/or GM for escalation Within 1 hour of calling pharmacy. Nurses & CMAs.
- Notify physician to request for alternative orders. ONLY for nurses.
- Document and carry out provider's instructions immediately. ONLY for nurses.
- Proper Protocol for all Facility Nurses and Medication aides of notification tree if medication is unavailable - DON Contact information is posted in med room.
- Contact GM Contact information is posted in Med Room.
- Contact assigned provider ONLY for nurses.
- Contents of medication dispensing machine and IV E-kits - see Attachment A.
- Inservices will be reinforced via the bulletin board of the electronic health records as well as live documents sent via text message.
- Inservice will be required to be completed prior to start of shift.
- There will be post test given and graded by CNO and/or GM.
- Nursing staff initiated a MAR-to-Cart audit of all in-house residents to ensure medications are available and to order/reorder medications that are not available in the medication carts.
- The medication lists of all new admissions will be matched with actual medications the following day by DON and or designee and will be ongoing process.
- Medications should be available by next delivery period and/or within 24 hours of order entry.
- If a medication is scheduled prior to pharmacy scheduled delivery run, nurses or certified medication aides are to pull first dose from the IV-ekit or medication delivery machine.
- Then follow regular delivery for the next dose.
- If medications are not available on the medication dispensing machine, the nurses and certified medication aides are expected to call for STAT delivery.
- List of medications available on the medication dispensing machine was posted by DON in the medication rooms.
- DON and/or designee will complete a daily audit of medications for new admissions.
- Then will be reduced to weekly x 2 weeks.
- Then move to random new admit medication audits.
- If there is missing medication, DON and/or designee will ensure that the notification tree was activated and will be ongoing process.
- Findings will be discussed weekly between GM, DON and/or designee and VP of clinical operations.
- There was an ADHOC QAPI meeting held with the General Manager, Administrator, Director of Nursing, Medical Director, Pharmacy Director, Chief Clinical Officer, and Regional VP of Clinical, after the IJ was called.
- Findings will also be presented during monthly QAPI meeting x3 months.
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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