Life Care Center Of Plano
Inspection history, citations, penalties and survey trends for this long-term care facility in Plano, Texas.
- Location
- 3800 W Park Blvd, Plano, Texas 75075
- CMS Provider Number
- 455864
- Inspections on file
- 30
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Life Care Center Of Plano during CMS and state inspections, most recent first.
Surveyors found that the facility’s activities program was being directed by an Activity Director who lacked the required certification or qualifying credentials. The Activity Director had been hired and functioning in the role for several months without meeting federal criteria for an activities professional or therapeutic recreation specialist, and she could not describe the risks to residents from her lack of qualification. The Administrator confirmed he had only recently learned she was not certified and acknowledged that this could affect her ability to recognize and address resident isolation, contrary to facility policy and regulatory requirements for a qualified individual to direct the activities program.
A resident with cognitive impairment and no prior history of elopement left the facility unsupervised by following a visitor out the front door, which was unlocked by the receptionist who did not recognize him as a resident. The resident was missing for over an hour before being found at a nearby apartment complex, with staff unaware of his absence until notified by external parties. Staff did not verify the resident's location, and elopement risk assessments and monitoring procedures were not effectively implemented, resulting in a deficiency for inadequate supervision and accident prevention.
The facility failed to ensure proper food storage, labeling, and sealing in both the walk-in refrigerator and freezer, and did not maintain temperature monitoring or logs for two chest freezers. During meal preparation, dietary staff did not use required hair or facial hair restraints and failed to follow proper hand hygiene protocols, including not washing hands between glove changes while handling food.
Three residents did not have their care needs and preferences accurately reflected in their care plans, including the use of psychotropic medication, specific ADL assistance, and a preference for being assisted by a family member. Staff interviews and observations confirmed these needs and preferences were known but not documented, resulting in incomplete person-centered care planning.
Two residents who were dependent on staff for ADL care did not receive adequate assistance with grooming and nail care. One resident with diabetes and other chronic conditions was observed with long, dirty fingernails on multiple days, while another resident with multiple diagnoses had long fingernails and facial hair that had not been addressed. Staff interviews revealed confusion about responsibility for nail care and a lack of attention to residents' grooming needs, despite facility policy requiring assistance with these tasks.
Staff failed to consistently perform hand hygiene and use EPA-approved disinfectants during incontinence care, blood glucose monitoring, and wound care for several residents with complex medical needs, resulting in lapses in infection prevention and control protocols.
Staff failed to keep a foley catheter drainage bag below the bladder during a mechanical lift transfer for a resident with severe cognitive impairment and multiple medical conditions. The drainage bag was observed above the bladder, contrary to physician orders and facility policy, and staff interviews revealed uncertainty about proper procedures during transfers.
Two residents did not receive respiratory care in accordance with professional standards: one received tracheostomy care from an LVN who failed to perform required hand hygiene and maintain sterile technique, while another received continuous oxygen therapy without a physician order specifying the amount to be administered. These failures were confirmed by staff interviews and review of facility policies.
A resident did not receive a timely dose of levothyroxine because staff failed to re-order the medication as required. When the medication was unavailable, an LVN borrowed it from another resident's supply instead of using the E-Kit, contrary to facility policy. Staff interviews confirmed that nurses are responsible for re-ordering medications when supplies run low and that the E-Kit should be used for missing doses.
A LVN left a medication cup with a pill on top of an unlocked medication cart and left the cart unattended while assisting a resident and administering medications to another. The LVN acknowledged the error, and the DON confirmed that staff are trained to keep medication carts locked and medications secured, as required by facility policy.
A CNA in an LTC facility failed to demonstrate competency in repositioning a resident according to the care plan, resulting in the resident grimacing in pain. The CNA grabbed the resident's neck to reposition him, contrary to the facility's policy, which prohibits pulling from the head of the bed. The resident, who had multiple cognitive and mental health diagnoses, required assistance with ADLs due to an ADL self-care performance deficit.
The facility failed to maintain proper kitchen sanitation, with observations revealing thick black buildup on the grease trap and food residue and grease on the stove. Interviews indicated inconsistent cleaning practices among kitchen staff, and the Food Services Director acknowledged outdated and unchecked cleaning schedules.
The facility failed to ensure that a resident's fall mat was placed on both sides of the bed as noted in the care plan. The resident, with a history of falls and severe cognitive impairment, was found without fall mats, which were rolled up in the corner of the room. Staff interviews confirmed that the mats should have been placed back immediately to prevent potential injury.
Unqualified Staff Directing the Activities Program
Penalty
Summary
The facility failed to ensure its activities program was directed by a qualified professional as required by regulation and facility policy. Record review showed the Activity Director was hired on 08/24/2024 and began performing activity duties on 10/18/2025. During an interview, the Activity Director reported she did not yet have her activity certification and stated that a previous administrator had agreed to pay for the certification, but it had not been obtained. When asked about the risk to residents from her lack of certification, she stated she did not have an answer. In a separate interview, the Administrator acknowledged he had just learned that the Activity Director was not certified. He stated that the risk to residents was that the Activity Director might not be able to identify if residents were isolating themselves or secluded and how to address that. Review of the facility’s “Therapeutic Activities Program” policy, dated 09/26/2025, showed it required that the activities program be directed by a qualified activities director responsible for directing the development, implementation, supervision, and ongoing evaluation of the activities program. Federal regulatory criteria cited in the report specify that the activities program must be directed by a qualified therapeutic recreation specialist or activities professional meeting defined licensure, certification, experience, or training requirements, which the current Activity Director did not meet at the time of the survey.
Resident Elopement Due to Inadequate Supervision and Failure to Identify Exit-Seeking Behavior
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, chronic kidney disease, and intermittent memory problems was able to leave the facility without staff awareness. The resident was admitted as oriented to person, place, and time, and initial elopement risk assessments did not identify him as at risk for elopement. However, the resident exited the facility by following a visitor out the front door, which was unlocked by the receptionist, who did not recognize him as a resident at the time. The resident was missing for approximately 1.5 hours before being located at a nearby apartment complex, after crossing a parking lot and service road. During the time the resident was missing, staff did not notice his absence. An LPN assumed the resident was in therapy and did not verify his location. The facility's elopement book and risk lists were not effectively used to identify or monitor the resident, and the receptionist was not aware of the resident's status. The incident was only discovered when the apartment complex staff contacted the facility, prompting the Maintenance Director to retrieve the resident. Law enforcement was also involved after being called to the apartment complex, where the resident was found confused and unable to explain how he had arrived there. The facility's policies required regular elopement risk assessments and quarterly elopement drills, but the resident's risk status was not updated until after the incident. Staff interviews revealed that while elopement drills and in-services had been conducted, there was a lack of immediate recognition and response to the resident's absence. The failure to provide adequate supervision and to ensure the area was free from accident hazards resulted in the resident's unsupervised departure and subsequent exposure to potential harm.
Food Storage, Preparation, and Staff Hygiene Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. In the walk-in refrigerator, bell peppers were found with wrinkling skin, softness, and white spots, indicating spoilage, and chicken noodle soup was not fully covered with plastic wrap. In the walk-in freezer, several food items including garlic bread, hash browns, and beef steak patties were found in torn or unsealed packaging, and packages of shrimp and brussels sprouts were not dated when received. The Dietary Manager confirmed that items should be dated, labeled, and sealed, and acknowledged that some items were not handled according to policy. Two chest freezers in the kitchen were found to be in use without thermometers, and there were no temperature logs maintained for these freezers. The chest freezers also had ice accumulation on the sides. The Dietary Manager was unable to locate thermometers for the freezers and admitted that temperature logs were not being kept. The Maintenance Director was unaware that the chest freezers were still in use and confirmed that they should have thermometers to ensure proper temperature maintenance. During lunch meal preparation and service, the Dietary Manager was observed plating food without a facial hair restraint for his mustache and failed to wash his hands between glove changes, despite handling food and touching the inner parts of plates. Another dietary staff member was observed with hair not fully covered by her hat while preparing food. Both staff members acknowledged awareness of the requirements for hair and facial hair restraints and proper hand hygiene, but did not comply with these standards during the observed meal service.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in deficiencies related to the documentation and communication of their care needs and preferences. For one resident with severe cognitive impairment and multiple diagnoses, the care plan did not reflect the use of psychotropic medication (Depakote) or the resident's dependence on staff for activities of daily living (ADLs), despite physician orders and staff interviews confirming these needs. The Director of Nursing and MDS Coordinator acknowledged that these aspects should have been included in the care plan to ensure staff awareness and appropriate interventions. Another resident, who was cognitively intact and required substantial assistance with ADLs, had a care plan that failed to specify the type of assistance needed or her preference for bed baths. Interviews with the resident and staff confirmed that bed baths were provided according to her preference, but this was not documented in the care plan. The care plan only included a general intervention to assist with ADLs as needed, lacking the specificity required for person-centered care. A third resident, who had quadriplegia and moderately impaired cognition, preferred to be fed and assisted with ADLs by a family member who was also a resident. Although staff and the residents themselves confirmed this preference, the care plan did not address it. The MDS Coordinator, Activity Director, and other staff agreed that this preference should have been documented to ensure all staff were aware and could honor it. The facility's policy required individualized, person-centered care plans based on resident assessments, but this was not consistently implemented for these residents.
Failure to Provide Adequate Assistance with Grooming and Nail Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene for two residents who were unable to perform these tasks independently. One resident, a female with a history of heart disease, type 2 diabetes, and hypertension, required substantial to maximal assistance with personal hygiene. Observations on two consecutive days revealed that her fingernails were approximately 0.5 inch in length with a dark brown substance underneath, indicating they had not been cleaned or trimmed. The resident reported she could not recall the last time her fingernails were trimmed and stated that no one had asked her about nail care. Staff interviews revealed confusion regarding responsibility for nail care, with CNAs believing nurses or the podiatrist were responsible, and nurses indicating that podiatrist visits were infrequent and that CNAs should clean the nails as needed. Another resident, a woman with diagnoses including enterocolitis due to clostridium difficile, morbid obesity, and muscle weakness, was observed to have facial hair about an inch long on her chin and fingernails that were 0.5-0.7 cm in length with a dark substance underneath. This resident was dependent on staff for showering, bathing, and toileting hygiene, and expressed a desire to have her facial hair removed and fingernails cut, stating that no one had asked her about these grooming needs. Staff interviews confirmed that the resident's grooming needs had not been noticed or addressed, and acknowledged that long and dirty nails could pose a risk of infection and negatively affect the resident's self-esteem. Review of the facility's policy on activities of daily living indicated that residents should receive assistance as needed to complete ADLs, including ensuring fingernails are clean and trimmed to avoid injury and infection. Despite this policy, the facility did not ensure that dependent residents received adequate assistance with nail care and grooming, as evidenced by the observations and staff interviews.
Failure to Adhere to Infection Control and Hand Hygiene Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to proper hand hygiene and equipment disinfection protocols during resident care. In one instance, a CNA provided incontinence care to a male resident with a history of infection and diabetes without performing hand hygiene before donning gloves, and again failed to sanitize hands when changing gloves between dirty and clean tasks. The CNA only performed hand hygiene after completing all care and handling trash, contrary to facility policy and infection control standards. During blood glucose monitoring for two residents with diabetes, LVNs did not follow required disinfection and hand hygiene procedures. One LVN used an alcohol prep pad instead of an EPA-approved germicide to clean the glucometer before and after use, citing a lack of appropriate supplies on the cart. Another LVN failed to perform hand hygiene after removing gloves and before handling an insulin pen, only sanitizing hands after preparing the medication. Both staff acknowledged awareness of the correct procedures and the risks associated with non-compliance. Additionally, during wound and incontinence care for a female resident with a sacral pressure ulcer, the Treatment Nurse did not perform hand hygiene after removing gloves and before re-gloving to continue wound care. This lapse occurred after cleaning a bowel movement and before re-treating the wound. The Treatment Nurse later confirmed that hand hygiene should have been performed at that point. Facility policy reviews confirmed that hand hygiene is required before and after resident contact, after glove removal, and after contact with blood or body fluids.
Failure to Maintain Foley Catheter Drainage Bag Below Bladder During Transfer
Penalty
Summary
Staff failed to maintain proper positioning of a foley catheter drainage bag for a resident who was incontinent of bladder and required total assistance with activities of daily living. During a mechanical lift transfer, the catheter drainage bag was observed being placed above the resident's bladder, first by being hooked onto the lift sling and then placed on the resident's lap, before finally being attached to the wheelchair. This was contrary to physician orders and facility policy, both of which required the drainage bag to be kept below the level of the bladder at all times to maintain unobstructed urine flow and prevent complications. The resident involved was a severely cognitively impaired female with multiple diagnoses, including diabetes, traumatic brain injury, respiratory failure, and neurogenic bladder, and had an indwelling catheter in place. Interviews with the staff involved revealed uncertainty and lack of clear instruction regarding the correct handling of the drainage bag during mechanical lift transfers, despite documentation indicating they had been deemed competent in catheter care. The facility's policy and physician orders were not followed during the observed transfer.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents requiring such care, as evidenced by direct observation, interviews, and record review. For one resident with a tracheostomy, an LVN did not perform hand hygiene at multiple required points during the tracheostomy care procedure. The LVN donned gloves and a gown without first sanitizing her hands, removed the old stoma dressing and inner cannula, and then proceeded to open and handle sterile supplies without hand hygiene. During the process, the LVN contaminated the sterile field by touching a non-sterile saline bottle and failed to maintain sterile technique throughout the procedure. The LVN acknowledged awareness of the correct sterile procedure and hand hygiene requirements but stated she was nervous and forgot to sanitize her hands. The facility's policy and staff interviews confirmed that tracheostomy care should be performed using sterile technique with hand hygiene before and after glove changes. Another resident was observed receiving continuous oxygen therapy via nasal cannula, but there was no physician order specifying the need for oxygen or the number of liters to be administered. The resident's care plan and physician order summary did not reflect any order for oxygen therapy, despite the resident stating she had been receiving oxygen since admission. Staff interviews confirmed that a physician order should have been in place prior to administering oxygen, and the absence of such an order was acknowledged as a failure to follow protocol. Both deficiencies were confirmed through interviews with nursing staff and the DON, who stated that proper procedures were not followed. The facility's policies on tracheostomy care and oxygen administration both require adherence to professional standards, including sterile technique and physician orders for respiratory treatments. The observed failures placed residents at risk for respiratory infections and incorrect oxygen administration.
Failure to Timely Re-Order and Securely Administer Medication
Penalty
Summary
Facility staff failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident. Specifically, staff did not re-order levothyroxine 50 mcg in a timely manner, resulting in a missed dose for a male resident with diagnoses including malnutrition and seizure disorder. The medication administration record indicated a missed dose, and there was no documentation in the progress notes to explain the omission. During medication administration, the nurse was unable to locate the medication and did not retrieve it from the E-Kit as required. Instead, the nurse borrowed levothyroxine from another resident's supply and administered it, which was confirmed during a subsequent interview. The nurse admitted to not following the proper procedure due to being in a hurry and not knowing why the medication had not been re-ordered. Other staff interviews confirmed that nurses are responsible for re-ordering medications when a 7-day supply remains and that the E-Kit is available for such situations. The facility's policy requires timely re-ordering and use of electronic systems to track medication needs.
Failure to Secure Medications and Lock Medication Cart
Penalty
Summary
A deficiency was identified when a Licensed Vocational Nurse (LVN) failed to properly secure medications on a medication cart in Hall E. During a medication pass, a medication cup containing a tan pill was left on top of the unlocked medication cart while the LVN assisted a resident in the bathroom. The LVN then left the cart unlocked and unattended again while administering medications to another resident in a different room. The LVN admitted to being distracted and acknowledged that the pill was an extra dose that should have been destroyed, and that medications should not be left unsecured or on top of the cart. The Director of Nursing (DON) confirmed that leaving the medication cart unlocked could allow unauthorized access to medications, and stated that staff are trained to keep carts locked and medications secured at all times. Facility policy requires all medications and biologicals to be securely stored in locked cabinets or carts, inaccessible to residents and visitors. The observed actions were not in compliance with this policy.
Inappropriate Repositioning Technique by CNA
Penalty
Summary
The facility failed to ensure that a Certified Nurse Aide (CNA) demonstrated competency in providing care according to the comprehensive care plan for a resident. The deficiency involved CNA A grabbing the resident's neck to reposition him in bed, which resulted in the resident grimacing in pain. This action was not in accordance with the facility's transfer and repositioning policy, which prohibits pulling from the head of the bed and manual patient repositioning. The resident involved was a male with multiple diagnoses, including cognitive impairment, dementia, psychotic disturbance, mood disturbance, anxiety, and other mental health conditions. The resident required assistance with activities of daily living (ADLs) due to an ADL self-care performance deficit related to activity intolerance and dementia. The care plan specified that the resident was totally dependent on 1-2 staff for repositioning and turning in bed every 2-4 hours or as necessary. The incident occurred when CNA A attempted to reposition the resident by grabbing his neck, which was captured on video. The resident's family had previously complained about the resident leaning to one side in bed, prompting CNA A to attempt repositioning. However, the method used was inappropriate and not aligned with the facility's policy, leading to the resident's discomfort and grimacing.
Failure to Maintain Kitchen Sanitation
Penalty
Summary
The facility failed to ensure proper sanitation in the kitchen, specifically regarding the grease trap and stove. Observations revealed a thick black buildup on the grease trap and food residue and grease buildup on the sides of the stove. Interviews with kitchen staff indicated that the cleaning responsibilities were not consistently followed, with some staff members not cleaning the grease trap or stove if they did not use certain equipment during their shift. The Food Services Director acknowledged that the cleaning schedule was outdated and not routinely checked for thoroughness, leading to the observed unsanitary conditions. Further observations confirmed that the grease trap and stove remained unclean despite the Food Services Director's efforts to address the issue. Interviews with multiple cooks revealed a lack of clarity and consistency in cleaning responsibilities, with some cooks not cleaning areas they did not use. The Food Services Director admitted that the grease trap required significant effort to clean and that it was his responsibility to ensure proper sanitation. The facility's cleaning policy and the US Public Health Service Food Code were not adhered to, resulting in the accumulation of grease and food residue on kitchen equipment.
Failure to Ensure Fall Mats in Place for Resident at Risk of Falls
Penalty
Summary
The facility failed to ensure that Resident #1's fall mat was placed on both sides of his bed as noted in his care plan. Resident #1, a [AGE] year-old male with a history of traumatic hemorrhage of the cerebrum, protein-calorie malnutrition, muscle weakness, history of falling, and vascular dementia, was observed lying in bed without fall mats on either side. The fall mats were found rolled up and propped in the corner of the room. Nurse Aide A admitted to rolling up the mats with the intention of transferring the resident to a wheelchair but left to find assistance without putting the mats back down. LVN B and the DON confirmed that the mats should have been placed back immediately to prevent potential injury from falls. Interviews with the staff revealed that it was the responsibility of both the nurse aides and nurses to ensure that fall mats were used for residents at risk of falls. The DON emphasized that staff should plan ahead and ensure mats are in place if they need to leave the room. The facility's policy on fall management, reviewed in December 2023, indicated that patient safety should be promoted by proactively identifying, care planning, and monitoring fall indicators. The failure to follow these protocols put Resident #1 at increased risk for accidents and injury.
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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