Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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 council meeting privacy deficiency occurred when meetings were regularly held in the dining room instead of a private space. Record review showed multiple resident council meetings took place there, and interviews confirmed the AD F was responsible for ensuring residents had a private place to meet but was unaware of the privacy requirement. The ADM and VPCO stated residents should be able to meet without staff present and have privacy when raising complaints or sharing input.
Missed bathing and grooming assistance for multiple residents. Several residents with ADL care needs and cognitive or physical impairments had incomplete shower documentation, reported delayed or absent showers, or had family report that preferred shower times were not being followed. Two residents were observed with chin hair, and staff stated facial hair grooming could be done during showers, but it had not been offered to them.
Failure to Perform Required Hand Hygiene During Food Prep and Tray Delivery: A dietary employee failed to wash hands between puree tasks and before donning clean gloves while preparing pureed foods, and a DA failed to wash hands before taking a tray-cart from the kitchen to deliver meal trays to a hall. Staff stated handwashing is required when entering the kitchen, between tasks, and before food prep, and the facility policy required handwashing before glove use and between kitchen activities.
Failure to perform hand hygiene between meal tray passes was observed when an aide passed lunch trays to multiple residents on the 100 Hall without sanitizing his hands between rooms. The aide stated he had been trained on hand hygiene and tray passing but forgot because he was moving fast, and he acknowledged this could lead to infection. The DON stated staff were required to use ABHR between meal passes per policy and that leadership monitored compliance.
Dirty Resident Rooms Not Maintained: Two residents had rooms that were not kept clean and orderly. One resident with dementia, falls history, and mobility issues and another resident with anxiety, morbid obesity, and impaired mobility were observed with paper, dirty socks, spoons, an empty medication cup, and hair in the shower area. Both residents stated housekeeping had not adequately cleaned their rooms, while the HKS, VPCO, and ADM said rooms were to be cleaned daily and housekeeping was responsible for maintaining them.
Unlocked Medication Cart Left Unattended: TC #1 was observed unlocked and unattended outside a resident's room while a nurse was inside the room and residents walked by the cart. The cart contained residents' prescribed creams, wound cleaner solution, and wound dressings. LVN C stated she had been trained that the cart must be locked whenever staff walk away, but she left it unlocked while speaking with a resident. The VPCO and ADM confirmed the cart should be locked whenever staff are not using it or cannot see it, and record review showed the facility's Medication Labeling and Storage policy did not cover medication storage.
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.
Resident Council Meetings Held in Dining Room Without Privacy
Penalty
Summary
The facility failed to provide a private space for resident council meetings. Record review of prior Resident Council Meeting minutes dated 10/23/2025, 11/20/2025, and 11/23/2025 showed that the meetings were regularly held in the facility dining room. During interviews, the AD F stated she had been trained in Resident Rights and in Abuse, Neglect, and Exploitation, and acknowledged that residents should be able to make choices and have a private place to meet. She also stated she was responsible for ensuring residents had a private place to meet. During a follow-up interview, AD F stated she was not aware of the privacy requirement for resident council meetings and said the dining room may not have been the best place to hold them. She stated she had thought the dining room was her only option and believed the meetings should take place in the privacy of the conference room from then on. The ADM stated residents should have privacy to make complaints when attending resident council meetings. The VPCO stated residents are allowed to meet without staff present and that if uninvited staff were walking through a room during a resident council meeting, residents may not be as candid with their comments, complaints, or input.
Missed bathing and grooming assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance with bathing and grooming. The deficiency involved five residents who had documented ADL care needs, including assistance with bathing and personal hygiene, but whose records and observations showed missed or inconsistently documented showers and, for two residents, no documented offer or assistance with facial hair removal. The facility’s own policies stated that residents would receive care according to their individualized care plans and that residents would be groomed as they wished, including facial hair being shaved or trimmed as the resident wished. Resident #31 had diagnoses including CHF, atrial fibrillation, CKD, anxiety, hypothyroidism, HTN, depression, hyperlipidemia, and vascular dementia, with a BIMS score of 7 and care plan needs for bathing and personal hygiene assistance. Her shower sheets showed refusals on some dates and showers on others, but during observation she was noted to have wispy chin hairs, and she stated it would be nice if someone offered to help with that. Resident #94 had diagnoses including CHF, diabetes, depression, anxiety, CKD, lymphedema, and spinal stenosis, with care plan needs for substantial/maximal bathing assistance and partial/moderate personal hygiene assistance. She was observed with facial hair on her chin and stated staff had not offered to help groom it. Staff later stated facial hair grooming for women could be done during the shower and that they had not offered to remove facial hair for either resident. Resident #57, Resident #76, and Resident #93 each had care plans identifying the need for assistance with bathing and personal hygiene, but their shower documentation showed gaps. Resident #57, who had diagnoses including acute kidney failure, anemia, morbid obesity, HTN, NASH, type 2 diabetes, hyperlipidemia, and glaucoma, stated it took the facility 7 days to bathe her after admission and that a family member had to intervene for her to receive a shower. Resident #76, who had diagnoses including a displaced subtrochanteric fracture of the left femur, dementia, anxiety, insomnia, GERD, dysphagia, and severe protein-calorie malnutrition, stated she had not received a shower since arriving and wanted one. Resident #93, who had diagnoses including metabolic encephalopathy, dementia, HTN, fractures of the left femur, pubis, and sacrum, hyperlipidemia, Alzheimer’s disease, and protein-calorie malnutrition, was non-interviewable, but her family member stated she preferred day showers, had requested showers during the day because of sundown syndrome, and had only received one shower since arriving at the facility. Staff interviews reflected that showers were supposed to be documented on shower sheets and in PCC, that residents were to be offered showers at least twice a week, and that refusals should be documented and followed up, yet the records for these residents showed no data or incomplete documentation for bathing history and no documented refusals in progress notes.
Failure to Perform Required Hand Hygiene During Food Preparation and Tray Delivery
Penalty
Summary
The facility failed to prepare and distribute food in accordance with professional standards for food service safety during kitchen and tray delivery operations. During observation on 01/13/2026, the [NAME] cleaned and disinfected the robot coup blender after pureeing tamale pie, then failed to wash her hands before putting on clean gloves. She later completed a puree of refried beans, removed her gloves, cleaned and sanitized the robot coup, and did not wash her hands before pureeing rice. The [NAME] stated she had training in food preparation and sanitation procedures, and stated the policy is to wash hands between kitchen and food preparation tasks. During observation on 01/15/2026, DA D, who had been trained in food safety and sanitation and stated he had worked at the facility since August 2025, failed to wash his hands before removing the food tray-cart from the kitchen to deliver food trays to the 100 hall. He stated handwashing is to be performed before leaving the kitchen to deliver food trays and that the policy requires sanitizing hands between tray delivery. The RD, DM H, and VPCO each stated that handwashing is required when entering the kitchen and between tasks, and the facility policy required thorough handwashing before food preparation, after unsanitary contact, and between removing gloves and putting on new gloves.
Failure to Perform Hand Hygiene Between Meal Tray Passes
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation on 01/13/2026 at 12:50 PM, DA D was observed passing lunch trays to residents on the 100 Hall and did not perform hand hygiene between residents. He left Resident #59's room, took a tray to Resident #26's room without sanitizing his hands, returned to the cart and took a tray to Resident #38's room without sanitizing his hands, and then returned to the cart and took a tray to Resident 67's room without sanitizing his hands. During interview on 01/13/2026 at 1:14 PM, DA D stated he had been trained to clean his hands with hand sanitizer between each resident when passing lunch trays, but said he had been moving fast and forgot to sanitize his hands. He also stated he had received training on hand hygiene and passing resident trays, and acknowledged that not conducting hand hygiene between each resident when passing meal trays could lead to infection. The DON stated the policy required all staff to use hand sanitizer between each meal pass unless handwashing was needed, and that nurse leadership and the DON were responsible for monitoring hand hygiene through spot checks, in-services, and checkoffs. Review of the facility's Hand Hygiene policy dated April 2023 reflected that staff were to comply with CDC hand hygiene guidelines and use alcohol-based hand rub before and after direct contact with residents, before and after contact with inanimate objects in the resident's immediate vicinity, and before and after assisting a resident with eating.
Dirty Resident Rooms Not Maintained
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two residents. Resident #22 was an older female admitted with diagnoses including embolism and thrombosis, atrial fibrillation, dementia, need for assistance with personal care, muscle weakness, history of falls, and unsteadiness on feet. Her MDS showed a BIMS score of 13, and her admission care plan identified her as at risk for falls related to history of falls and decreased mobility. Resident #71 was an older female admitted with diagnoses including anxiety, morbid obesity, need for assistance with personal care, difficulty walking, pain due to trauma, and injury from a motor vehicle collision. Her MDS showed a BIMS score of 15, and her admission care plan identified her as at risk for falls related to impaired mobility, fractures, pain, and post-surgical state. On observation, Resident #71's room had paper on the floor, dirty socks on the floor, an empty medication cup under the bed, and hair on the bathroom shower wall. The same conditions were observed again later that day and again the next morning. Resident #22's room was also observed with a paper towel on the floor, small pieces of paper on the floor, and two spoons on the floor under her bed. During interview, Resident #71 said housekeeping had not come to sweep, mop, or clean her bathroom and that visitors commented on how dirty her room was. Resident #22 said housekeeping only cleaned once a day and staff left items for housekeeping. The HKS, VPCO, and ADM stated that resident rooms were to be cleaned daily, that housekeeping was responsible for cleaning the rooms, and that nursing staff should help keep rooms tidy when housekeeping was not present. The HKS also stated the rooms were probably dirty because the facility only had one housekeeper because the other was out sick.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored properly and that only authorized persons had access to them for 1 of 2 medication carts reviewed, identified as TC #1. During an initial walkthrough on 01/13/2026 at 09:01 a.m., TC #1 was observed unlocked and unattended outside a resident's room while a nurse was inside the room with her back turned away from the cart. The resident's door was cracked open about two inches, and residents were walking by the cart. TC #1 contained residents' prescribed creams, a bottle of wound cleaner solution, and two packages of black foam wound dressings, one of which was opened. During interviews, LVN C stated she had been trained on medication storage and that the cart should be locked anytime staff walked away from it, including immediately after removing medication and before leaving the cart unattended. She said she left the cart unlocked because she walked into the resident's room to talk to the resident and later locked it when she came back out. The VPCO and ADM also stated the cart should be locked whenever staff were not using it or were not in sight of it, and that the assigned nurse or medication aide was responsible for locking it. Record review showed the facility's Medication Labeling and Storage policy dated January 2026 did not cover medication storage, and the medication storage policy was not provided upon exit.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 341 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Center At Parmer | 1.2 mi | ★★★★★ | 18 | 0 |
| Park Valley Inn Health Center | 1.6 mi | ★★★★★ | 10 | 0 |
| Hearthstone Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 7 | 0 |
| Trinity Care Center | 3.9 mi | ★★★★★ | 9 | 0 |
| Windsor Nursing And Rehabilitation Center Of Duval | 5.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Ignite Medical Resort Round Rock, Llc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.