Memorial Medical Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 307 W Cypress St, San Antonio, Texas 78212
- CMS Provider Number
- 455597
- Inspections on file
- 45
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Memorial Medical Nursing Center during CMS and state inspections, most recent first.
The facility failed to maintain comprehensive, person-centered care plans that reflected current behaviors, refusals, and psychosocial needs for three residents with dementia and mental health diagnoses. One resident repeatedly refused showers over a month, with refusals documented in task records and discussed by staff, yet the care plan did not address shower refusal or related interventions. Another resident with severe cognitive impairment exhibited documented verbal and physical aggression toward staff, refused medications, care, and weight checks, and was involved in a resident-to-resident altercation, but her care plan was not revised to include these behaviors or associated psychosocial needs despite MDS triggers. A third resident with Alzheimer’s disease and major depressive disorder made a suicidal statement that led to 1:1 observation, psychiatric evaluation, and antidepressant dose adjustment, yet her care plan was not updated to address suicidal ideation or related psychosocial interventions, even though IDT discussions and interventions were reported by leadership and clinical staff.
The facility failed to report two separate incidents involving alleged abuse and suicidal ideation in accordance with required timeframes and its own abuse policy. In one case, two residents sharing a room were involved in a resident-to-resident altercation in which one reported being slapped in the face by the other; staff separated the residents, completed assessments, and documented the event as a resident-to-resident incident, but did not report it as an abuse allegation to the State. In another case, a resident with a history of major depressive disorder and recurrent SI reportedly stated an intention to kill herself; nursing staff documented the report, performed a safety assessment, and a psychiatric provider later documented that the resident had voiced wanting to kill herself when upset, yet this incident was also not reported as required. Leadership interviews confirmed that these events were internally reviewed but not submitted as abuse or neglect allegations to the State Survey Agency, despite facility policy requiring immediate reporting of all alleged violations.
The facility failed to ensure that MDS assessments accurately reflected the behavioral and mood status of two residents with dementia and psychiatric diagnoses. One resident’s admission MDS indicated no physical or verbal behaviors toward others, even though nursing notes and an incident report documented repeated verbal and physical aggression toward staff and a roommate, including slapping and combative behavior during ADLs. Another resident’s significant change and quarterly MDS assessments did not capture documented episodes of verbal and physical aggression toward a roommate, as well as a reported suicidal statement that led to 1:1 observation and psychotropic medication adjustment. Although care plans and staff interviews confirmed ongoing behavior issues and interventions, the MDS assessments were not updated to reflect these behaviors or mood changes, contrary to facility policy and RAI requirements.
The facility failed to maintain complete and accurate medical records for two residents related to medication administration and monitoring. For one resident receiving Methocarbamol for muscle spasms, the MAR and Medication Administration Audit Report showed a scheduled evening dose documented as given the following morning, and the medication aide admitted she delayed documentation after administering medications while assisting other staff. For another resident on antianxiety medication with cognitive impairment, an LVN documented "N" on the MAR, which per the order indicated the presence of side effects requiring progress note documentation, but no side effects were charted. Both the ADON and the LVN reported that the order’s requirement to use "Y" for no side effects and "N" for side effects was confusing and led to incorrect entries, resulting in medical records that did not accurately reflect the residents’ medication administration and monitoring.
A resident with a sacral surgical wound, diabetes, severe malnutrition, and moderate cognitive impairment had physician orders for daily cleansing, packing with Iodoform, and dressing changes to the wound, supported by a care plan that included specialized mattress use, barrier precautions, and weekly skin checks. Wound measurements over time showed improvement and stabilization, but review of the TAR revealed that ordered wound care was not performed on multiple days across two months. A family member reported poor incontinence and wound care, providing photos showing an unchanged bandage over several days. The wound nurse (LVN) acknowledged that wound care was not done on the missed days, stating she was working the floor and had expected an unidentified back-up nurse to complete the treatments. The NP and DON confirmed that the wound had remained stable and that the resident was transferred to the hospital for seizure-like symptoms rather than wound issues, but facility policies required wound treatment to be provided as ordered, which did not occur on the documented dates.
Two residents experienced unresolved maintenance issues in their rooms, including inaccessible bathroom and bedroom doors, broken or missing tiles, exposed wall holes, and damaged baseboards. Additionally, the patio entry door lacked a proper closing mechanism and had a gap at the threshold, making access difficult and unsafe for wheelchair users. These deficiencies were reported by residents and observed by staff, but repairs were not completed in a timely manner.
Multiple residents were found with unsecured medications at their bedsides, including prescription inhalation solutions, medicated ointments, eye drops, antacids, magnesium hydroxide, and vitamins. Some of these residents had cognitive impairments and were not authorized to self-administer medications. Facility policy and staff statements confirmed that only authorized personnel should have access to medications, but these protocols were not followed.
A resident with multiple complex medical conditions did not have a nursing admission assessment documented in the clinical record. The assessment was missing after the admitting nurse left due to a family emergency, and although the Administrator and ADON entered physician orders and medications, the required nursing assessment was not completed or found in the electronic record.
A resident with chronic respiratory conditions was observed using a nebulizer mask and tubing that had been left on a nightstand instead of being stored in a bag as required by infection control protocols. Staff interviews confirmed the equipment was not stored properly and that the resident, who was moderately cognitively impaired, self-administered her treatment, contrary to orders. The failure to follow proper storage procedures for respiratory equipment resulted in a deficiency in the facility's infection prevention and control program.
Three residents did not have comprehensive, person-centered care plans addressing all identified needs as required. One resident's care plan omitted multiple care areas triggered by the MDS assessment and was completed late. Another resident's use of smokeless tobacco was not included in their care plan, and staff were unaware of this need. A third resident's care plan only addressed group activities and code status, missing all other required care areas after a hospital return.
Surveyors observed that clean mugs were stored face-down on wet trays without air-drying nets, and a soiled mop and broom were stored head-side down in a utility closet rather than being hung to dry. The Dietary Manager confirmed these practices did not follow facility policy for air-drying and sanitary storage, as required for food service safety.
Staff failed to follow infection control protocols by not changing gloves or sanitizing hands after touching environmental surfaces and during resident care, including colostomy, wound, and incontinent care for two residents with complex medical needs. These lapses were observed among an LVN and a CNA, both of whom had received infection control training, and were confirmed through staff interviews and facility policy review.
A LVN did not fully close the privacy curtain while providing wound care to a resident with multiple medical conditions and cognitive impairment, resulting in the resident's buttocks being exposed and visible to anyone entering the room. Both the LVN and DON confirmed that privacy should have been maintained and that staff had received training on resident rights.
A resident with multiple complex medical conditions and moderate cognitive impairment was not accurately assessed for current tobacco use. The MDS assessment and care plan failed to reflect the resident's ongoing use of smokeless tobacco, which was confirmed through observation and resident interview. Nursing staff and the DON were unaware of the tobacco use, and the error was linked to the assessment being completed by an interim corporate RN.
A resident with a new diagnosis of schizoaffective disorder, bipolar type, was not referred for a Level II PASRR evaluation after a significant change in mental health status. The resident, who had moderate cognitive impairment and was prescribed antipsychotic medication, did not have a referral made due to a lack of communication and follow-through by the corporate MDS coordinator, despite facility policy requiring such coordination.
A resident with severe cognitive impairment and multiple medical conditions refused to be weighed, but this refusal was not documented in the comprehensive care plan as required. Although CNAs recorded the refusal in the EHR, nursing staff did not update the care plan to reflect the resident's wishes, contrary to facility policy.
A resident with a tracheostomy did not receive care according to professional standards when an RN broke sterile technique by placing non-sterile items on the sterile field and crossing it with non-sterile arms during the procedure. The resident, who was nonverbal and required extensive assistance, had orders and a care plan specifying sterile tracheostomy care every shift. The RN was unaware of the breach at the time, and the DON confirmed that sterile technique was required.
A nurse failed to maintain sterile technique while providing tracheostomy care to a resident with complex medical needs, resulting in a break of sterile field during the procedure. Despite documented training and competency checks, the nurse was unaware of the breach, which was confirmed through observation and interviews. Facility policy and physician orders required strict sterile technique for tracheostomy care.
A resident's personal refrigerator contained multiple food items, such as cooked sausage and canned peaches, that were not labeled or dated according to facility policy. The DON confirmed that staff are responsible for monitoring food labeling and dating, but noted that residents sometimes refuse access to their refrigerators. Facility policy requires all food items stored for later consumption to be labeled with the resident's name and date, and for refrigerators to be monitored daily.
A facility failed to maintain an effective pest control program, resulting in recurring gnat infestations in a resident's room. Staff and the DON confirmed the ongoing issue, and records showed that while pest control services were provided for other pests, gnats were not specifically treated. The problem was linked to sanitary concerns in the affected room.
A dumpster used for garbage and refuse disposal was found to be missing a required drain plug, contrary to facility policy and federal Food Code. Staff were unaware of the missing plug until it was identified during a survey, and the previous dumpster did not require a plug. The absence of the drain plug meant the dumpster was not maintained in a manner inaccessible to pests, as required.
A resident with severe cognitive impairment and multiple medical conditions received Hydromorphone for pain management, but the facility failed to maintain accurate drug records and reconcile controlled substances. Discrepancies were found between the narcotic reconciliation log and the MAR, with missing signatures and undocumented doses. Nursing staff were found to have signed for doses not administered and attempted to have others do the same, contrary to facility policy requiring immediate and accurate documentation.
A resident with multiple chronic conditions received supplemental oxygen, CPAP, and BiPAP without a physician's order, resulting in incomplete and inaccurate medical records. Nursing staff documented the use of these therapies in progress notes, but failed to ensure proper physician authorization and transcription into the resident's official orders, contrary to facility policy.
A resident's call light system was found to be inoperable, failing to produce a visible or audible signal. The resident, who requires moderate assistance and has a history of falls, was unaware of the malfunction. The Maintenance Director and an LVN were also not aware of the issue, which contravenes the facility's policy requiring operational call lights at all times.
The facility failed to maintain a safe environment in the West Hall Downstairs, where an overhead light and ceiling heater in two unmarked resident shower rooms were found inoperable. The Maintenance Director and ADON-A were unaware of these issues, which could affect resident safety due to diminished lighting. The facility's policy requires all equipment to be maintained in a safe and operable manner.
A cognitively impaired resident eloped from a facility due to inadequate supervision and security measures. Despite being at risk for elopement, the resident left through an unknown door and was found at a hospital the next day. Staff interviews revealed multiple facility doors with alarms that could be easily disabled, and a lack of awareness regarding the resident's elopement risk. The facility's policy on wandering and elopements was not effectively implemented, leading to the incident.
The facility failed to make the most recent survey results readily accessible to residents, family members, and legal representatives. During a facility tour, it was observed that there was no survey results binder or sign indicating its location. Staff interviews revealed confusion about the binder's location, which was eventually found in the Medical Records office. The administrator cited an administrative transition as a reason for the oversight, and the DON noted that the survey book had been moved during renovations.
The facility failed to maintain sanitary conditions in the kitchen when a CNA entered without a hair net, contrary to policy and training. The absence of hair nets in the designated container was noted, and staff interviews confirmed the importance of wearing hair nets to prevent contamination. The Dietary Manager and DON emphasized compliance with this requirement.
The facility did not post detailed nurse staffing information per shift in a prominent place, as required. Observations revealed that the posted documents only showed total staff numbers for a 24-hour period, not per shift, and were placed in areas not easily accessible to residents and visitors. The DON confirmed the format used was based on previous practices, which did not comply with the facility's policy.
A resident with severe cognitive impairment was involved in a suspected abuse case that was not reported immediately by two CNAs. The CNAs observed a discharge they believed to be semen but did not report it to the charge nurse or abuse coordinator until the following morning, violating facility policy and federal requirements for immediate reporting.
The facility failed to adhere to professional standards for food service safety, including unlabeled and undated food items, a malfunctioning ice cream freezer, and poor kitchen sanitation. Observations revealed multiple instances of non-compliance, and interviews with staff highlighted lapses in maintenance and adherence to food safety policies.
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous flies in a resident's room and in the Main Dining Room. Flies were observed landing on a resident and on another resident's food and drink, despite the facility being serviced by pest control three times in April.
The facility failed to ensure residents and/or their representatives the right to participate in the development and implementation of their person-centered care plans. Four residents were not invited or included in Care Plan Conference meetings, leading to concerns about their care and physical decline. Interviews with staff revealed inconsistencies and gaps in the care plan conference process.
The facility failed to develop comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs, such as broken teeth, diet, assistance with activities of daily living, and discharge plans. The MDS Coordinator confirmed these deficiencies, acknowledging potential shortfalls in care.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent weekly skin assessments as ordered, leading to missed or delayed identification of new wounds. Staff interviews revealed inconsistencies in performing and documenting these assessments, and facility policies were not adequately followed.
The facility failed to ensure a safe environment by allowing residents to possess cigarettes, lighters, and sharp objects, and by leaving storage and shower rooms unlocked with hazardous items accessible. The Administrator confirmed these items should have been secured.
The facility failed to provide appropriate respiratory care for four residents requiring oxygen therapy. One resident did not have proper orders for oxygen support devices, and her oxygen tubing was not changed as needed. Three other residents had empty oxygen humidifier bottles that were not replaced as per physician orders, leading to potential respiratory complications. The DON acknowledged the oversight, attributing it to agency night shift nurses.
The facility failed to ensure safe and sanitary storage of food items in two residents' personal refrigerators, which contained unlabeled and undated food. CNA B confirmed the presence of these items, and the DON acknowledged that night shift nurses were responsible for monitoring this task, which was not being done.
The facility failed to maintain an infection prevention and control program, as evidenced by an overfilled sharps container in a resident's room. The resident had severe cognitive impairment and multiple medical conditions. During a blood sugar check, an LVN was unable to dispose of used sharp supplies in the overfilled container, posing a risk of puncture and infection. Interviews revealed that while central supply was responsible for replacing containers, nurses had access to do so themselves. The DON acknowledged the risk and her responsibility for infection control.
The facility failed to enforce its smoking policies, allowing residents to keep cigarettes and lighters in their rooms despite policy prohibitions. Residents were observed smoking in the courtyard and admitted to keeping smoking materials in their rooms, contrary to the facility's guidelines.
The facility failed to develop and revise comprehensive care plans for two residents, omitting necessary interventions for insulin administration despite physician orders and diagnoses of diabetes. Interviews with staff confirmed that these omissions should have been included in the care plans.
Failure to Update Person-Centered Care Plans for Behavioral Symptoms, Refusals, and Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive, person-centered care plans with measurable objectives and time frames for multiple residents whose needs and behaviors had been identified through assessments, progress notes, and incidents. For one male resident with Alzheimer’s disease, cognitive communication deficit, impulse disorder, and major depressive disorder, the quarterly MDS showed moderate cognitive impairment. Task records for bathing over a 30‑day period documented that this resident accepted only two baths and refused eight, and the facility’s grievance log showed he complained of not being changed and not being showered. During interview, he denied refusing showers, while staff, including an LVN and the DON, stated he sometimes refused showers despite encouragement and that such refusals should be reflected in the care plan to respect his right to refuse and guide staff in offering and encouraging hygiene. However, his care plan contained no mention of shower refusals. A second female resident with Alzheimer’s disease, anxiety disorder, depression, spastic hemiplegia, and severely impaired cognition was totally dependent for self‑care and mobility and used a manual wheelchair. Her admission MDS triggered care areas and documented cognitive loss/dementia, communication issues, falls, and psychotropic drug use, but did not include review or revision addressing psychosocial well‑being, behavioral symptoms directed toward others, or refusal of medications and care. Progress notes over several days documented repeated episodes of verbal and physical aggression toward staff during ADL care, including striking or attempting to hit, push, and grab staff, as well as multiple refusals of care, refusal of all medications, and refusal of weight checks. An incident report and progress notes also documented a resident‑to‑resident incident in which she slapped her roommate, after which the residents were separated and she was placed near the nurse’s station. Despite these documented behaviors and refusals, her care plan, dated and revised in February, addressed cognitive impairment, language barrier, and potential adverse effects of antidepressants but did not include revisions to reflect her aggressive behaviors, refusals, or related psychosocial needs. A third female resident with Alzheimer’s disease, recurrent major depressive disorder, suicidal ideations, repeated falls, and cognitive communication deficit had severely impaired cognition but could perform some self‑care with help and used a manual wheelchair independently. Her care plan included problems and interventions for physical functioning deficits, physically abusive behavior (cursing, yelling, throwing items), potential adverse effects of antidepressants, impaired communication, dementia‑related complications, and refusal of care, with interventions such as room changes, documenting behaviors, obtaining antianxiety medication, identifying root causes of refusal, and using clear communication. However, following an incident in which she reportedly stated she was going to kill herself, nursing documentation described immediate safety assessment and her denial of suicidal ideation, and a psychiatric NP note described that she had been placed on 1:1 observation after the reported suicidal statement, denied current SI, and had her sertraline dose increased, with instructions to staff to report any return of suicidal thoughts. A psychology progress note later documented that she denied SI/HI/AVH. Despite these documented suicidal ideation symptoms and related psychiatric interventions, there was no review or revision of her care plan to address her psychosocial well‑being or suicidal ideation following the incident. Interviews with regional and facility leadership, including the Regional Nurse, MDS Coordinator, ADON, DON, Senior Director, and former ADM, confirmed that IDT meetings occurred and interventions were discussed and implemented for residents with behavioral issues and suicidal ideation, but acknowledged that the MDS assessments and care plans for these residents were not updated to reflect the documented behaviors, refusals, and psych service interventions, contrary to facility policies on comprehensive care plans, MDS completion, and abuse/neglect prevention that require ongoing assessment and care planning for residents with behaviors that might lead to conflict or neglect.
Failure to Report Alleged Abuse and Suicidal Ideation Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to immediately report alleged abuse and suicidal ideation to the administrator and State Survey Agency as required by policy and federal regulations. On one occasion, a resident with Alzheimer’s disease, anxiety, depression, and severe cognitive impairment (Resident #4) was alleged to have slapped her roommate (Resident #5) in the face while the roommate was eating breakfast in their shared room. A registered nurse documented that when she entered the room, the roommate warned her to be careful because the other resident had slapped her. The nurse separated the two residents, assessed them, and documented that vital signs were stable and no injuries were observed. An incident report was completed describing the resident-to-resident altercation and the immediate actions taken, including placing one resident in front of the nurse’s station, but this allegation of physical abuse was not reported to the State. A second incident involved suicidal ideation by Resident #5, who had diagnoses including Alzheimer’s disease, major depressive disorder, recurrent suicidal ideations, repeated falls, and a cognitive communication deficit. A nurse’s progress note documented that another nurse reported hearing this resident state, “I am going to kill myself,” while walking down the hallway. The nurse immediately located the resident, assessed for safety, and documented that the resident denied making the statement and denied any suicidal ideation, intent, or plan, appearing calm and in good spirits with no signs of emotional distress. A psychiatric mental health nurse practitioner later documented that the resident had been placed on 1:1 observation after it was reported she voiced wanting to kill herself, that the resident denied current suicidal ideation and any plan or intent, and that the resident stated she had made the statement because she was upset but did not mean it. Despite these documented reports of suicidal statements and the resident’s history of suicidal ideations, this incident was not reported to the State as an allegation of abuse or neglect. Interviews with facility staff and leadership confirmed that these events were treated as internal incidents but not reported externally as required. The Regional Nurse acknowledged awareness of the resident-to-resident incident in which one resident accused her roommate of slapping her, and stated that after assessments showed no injuries and no witnesses, she recommended not reporting the incident to the State. She also stated that the suicidal ideation incident was assessed and followed by multiple clinicians, and that she did not believe it required State reporting. The MDS Coordinator similarly stated that the interdisciplinary team reviewed the physical and verbal incidents and the suicidal ideation but did not believe they required reporting. The Senior Director, however, stated that if a resident reported another resident was physically aggressive or expressed wanting to hurt themselves, this would warrant an abuse report. The former administrator reported she was not informed of the suicidal ideation incident or the later resident-to-resident incident and stated that, had she been made aware, she would have reported them to the State. Facility policy on Abuse, Neglect and Exploitation required immediate investigation of suspected abuse and reporting of all alleged violations to the administrator and state agency within specified timeframes, including within two hours for allegations involving abuse, but these procedures were not followed for the two incidents involving Residents #4 and #5.
Inaccurate MDS Coding for Behavioral Symptoms and Mood
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Minimum Data Set (MDS) assessments accurately reflected the behavioral and mood status of two residents with dementia and psychiatric diagnoses. For one resident with Alzheimer’s disease, anxiety, depression, and spastic hemiplegia, the admission MDS documented severely impaired cognition, total dependence in self-care and mobility, and no physical or verbal behavioral symptoms directed toward others. Despite this, multiple nursing progress notes around the time of admission described the resident as verbally and physically aggressive toward staff during ADL care, including striking at a CNA, attempting to hit, push, and grab staff, and being combative and refusing medications, weights, and care. An incident report and nursing note also documented that this resident slapped her roommate in the face, leading to separation of the residents and placement of the aggressive resident near the nurse’s station. These documented behaviors were not reflected in the admission MDS, and the triggered care areas did not include psychosocial well-being or behavioral symptoms directed toward others. The same resident’s care plan, initiated and revised shortly after admission, addressed cognitive impairment, impaired communication due to a language barrier, and potential adverse effects of antidepressant medications, but there was no documented review or revision of the care plan following the admission MDS assessment that had triggered care areas such as cognitive loss/dementia, communication, falls, and psychotropic drug use. Staff interviews corroborated that this resident was verbally and physically aggressive when she first arrived, often swinging at staff during care, and that she could be more agitated in the afternoons. CNAs, a medical assistant, and physical therapy staff all described a pattern of aggression and the need for de-escalation techniques and family involvement, yet these ongoing behaviors and related interventions were not captured in the MDS assessment or reflected in updated care planning tied to that assessment. For a second resident with Alzheimer’s disease, major depressive disorder, recurrent suicidal ideation, repeated falls, and a cognitive communication deficit, the quarterly and significant change MDS assessments documented severely impaired cognition, some need for help with self-care, independent mobility, and no physical or verbal behavioral symptoms directed toward others. However, facility records showed that this resident had a history of physically and verbally aggressive behavior, including cursing, yelling, throwing items, and a documented incident where she punched a roommate in the jaw during a dispute over a privacy curtain. An incident report described this resident as verbally and physically aggressive toward her roommate, resulting in a room change and notification of leadership and the physician. The resident’s care plan included a problem for physically abusive behavior with interventions such as room change, behavior documentation, and obtaining antianxiety medication, but the MDS did not reflect these behaviors. Additionally, this second resident experienced an episode of suicidal ideation when she reportedly stated she was going to kill herself while walking down the hallway. A nurse documented locating and assessing the resident, who then denied making the statement and denied suicidal ideation, intent, or plan. A psychiatric mental health nurse practitioner note on the same date recorded that the resident had been placed on 1:1 observation after voicing a desire to kill herself, that she later denied active or passive suicidal ideation, and that her sertraline dose was increased. Despite this episode and the implementation of psychotropic medication changes, the subsequent quarterly MDS did not accurately reflect Section D – Mood in relation to suicidal ideation, and there was no documented review or revision of the care plan addressing psychosocial well-being following this incident. Interviews with the regional nurse, MDS coordinator, ADON, senior director, and former administrator confirmed awareness of the resident-to-resident incidents and suicidal ideation, acknowledged that IDT meetings occurred and interventions were implemented, and attributed the lack of MDS updates to staff turnover, documentation errors, and failure to revise assessments as required by facility policy and the RAI Manual. The facility’s own MDS 3.0 Completion policy stated that residents are to be comprehensively assessed to identify care needs and develop an interdisciplinary care plan, and that a Significant Change in Status Assessment must be completed within 14 days of identifying a qualifying status change. Leadership interviews indicated that changes in cognition, ADLs, behavior, and psych interventions or medications could constitute a significant change, yet the behavioral aggression and suicidal ideation episodes for these two residents were not incorporated into updated MDS assessments. As a result, the assessments did not accurately reflect the residents’ physical and verbal behavioral symptoms directed toward others or mood status, despite clear documentation of these issues in progress notes, incident reports, psychiatric evaluations, and staff interviews.
Incomplete and Inaccurate Medication Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and systematically organized medical records for two residents. For the first resident, an adult female with muscle weakness and low back pain, the medical record included a physician’s order for Methocarbamol 750 mg by mouth three times daily for muscle spasms. The Medication Administration Audit Report showed the medication was scheduled for administration at 9:00 PM on 03/03/2026, but the record reflected administration at 06:03 AM on 03/04/2026 instead. The medication aide stated she was supposed to administer medications within one hour before or after the scheduled time and acknowledged she forgot to document immediately after administration because she was helping other staff before clocking out, although she stated she always ensured medications were given on time. The resident reported receiving medications on time, but the documentation did not accurately reflect the time of administration as required by facility policy, which directs staff to sign the MAR after administering medication. For the second resident, an adult male with an anxiety disorder, cognitive communication deficit, memory problems, and severely impaired decision-making, the facility had a care plan and physician’s orders requiring monitoring for side effects of antianxiety medication. The order specified that staff should observe for behaviors and side effects such as drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior, and document “Y” if the resident was free of side effects and “N” if side effects were present, with further documentation in progress notes if “N” was recorded. The January 2026 Medication Administration Record showed that an LVN documented “N” on two daytime shifts, indicating the presence of side effects, but there were no corresponding progress notes describing any side effects on those dates. Interviews revealed that both the ADON and the LVN found the wording of the antianxiety monitoring order confusing, particularly the requirement to use “Y” for no side effects and “N” for the presence of side effects. The LVN stated that when he marked “N” on the MAR, he intended to indicate that the resident was not experiencing side effects, and that he would have documented in the progress notes if side effects had been present. The ADON acknowledged the order’s wording was confusing and stated it was affecting nursing documentation. Observations on the survey date showed the resident did not respond to questions and was not exhibiting side effects or behaviors related to the antianxiety medication, but the existing records did not accurately reflect the resident’s status due to the misinterpretation and incorrect use of the “Y” and “N” indicators on the MAR.
Missed Daily Wound Treatments for Surgical Sacral Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatment and care according to physician orders and professional standards for one resident with a sacral surgical wound. The resident, an older female with a primary admission diagnosis of aftercare for a surgical tailbone wound and comorbidities including Type 2 diabetes, severe protein-calorie malnutrition, hypotension, hypertension, and a history of substance use, was admitted and later discharged to the hospital for seizure-like symptoms. Her quarterly MDS showed moderate cognitive impairment (BIMS 11), incontinence of bowel and bladder requiring substantial to maximal assistance, and dependence on a wheelchair with substantial to maximal assistance for transfers and mobility. The care plan included interventions for an altered sacral and lower back skin condition, such as an air loss mattress, barrier precautions, weekly skin inspections, and participation in an IV infusion program to promote healing and reduce infection risk. Serial wound assessments documented a sacral surgical wound that initially measured 4.0 cm x 3.5 cm x 3.0 cm and then showed progressive improvement and stabilization over multiple subsequent measurements, with the most recent measurements indicating a smaller but still present wound. Physician orders directed that the sacral surgical incision be cleansed with normal saline or wound cleanser, patted dry, packed with Iodoform strip, and covered with a dry dressing daily and as needed for soilage or removal, with wound management to occur every day shift. However, review of the Treatment Administration Record (TAR) showed that ordered wound care was not done on three separate days in one month and on one day in the following month. An email from a family member to the surveyor included photographs showing the same bandage in place over multiple days, suggesting that dressing changes had not occurred as ordered. During interviews, the wound nurse (LVN) acknowledged that wound care was not documented on the identified dates and stated she had been working on the floors as a nurse on those days, expecting an unidentified back-up nurse to perform the wound care; she could not recall who the back-up nurse was and confirmed that wound care was not done on at least one of the missed days. The NP reported that the wound had improved and stabilized over time, with no signs of infection or fecal or urinary contamination, and stated that nurses needed to follow MD orders and that there was no excuse for missed wound care. The DON stated that the resident received incontinence care at least every shift, that weekly skin assessments showed no breakdown or infection from incontinence, and that the resident was sent to the ER for seizure-like symptoms rather than wound issues, only becoming aware of the missed wound care days when informed by the surveyor. The resident’s representative alleged that the resident did not receive proper incontinence care and wound care, reporting feces and urine around the surgical wound and providing photos of what they believed to be a worsening wound. Facility policies on wound treatment management and pressure injury prevention required that wound treatment be provided in accordance with physician orders, but the documented missed treatments showed that this standard was not met for this resident.
Failure to Maintain Safe, Clean, and Accessible Resident Environment
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment for its residents. Specifically, two resident rooms and one patio door entry were observed to have unresolved maintenance issues. In one case, a resident who utilized a wheelchair reported that the bathroom door in his room only opened a quarter of the way, making the bathroom inaccessible, and the bedroom door did not close properly due to a broken hinge. The resident stated he had informed the Maintenance Director of these issues, but they remained unresolved, impacting his privacy and ability to accommodate visitors. Another resident's room was found to have a missing plate around a pipe above the bed, exposing a hole in the wall, as well as missing or torn rubber baseboards and broken or missing tiles in the shower. The resident reported having informed CNA staff about these issues weeks prior, but repairs had not been completed. The resident expressed dissatisfaction with the living conditions, noting that the environment made him feel bad and that maintenance had not addressed the problems on his side of the unit. Additionally, the entry/exit door to the patio, which led to the smoking area, was observed to close rapidly due to a missing mechanism, and there was a gap between the ramp and the threshold. Residents using wheelchairs had difficulty entering the building, sometimes requiring staff assistance, and one resident reported nearly falling due to the condition of the ramp and door. Staff interviews confirmed that these issues had persisted for some time, and the Maintenance Director acknowledged awareness of some problems but had not completed repairs. The Administrator was not aware of all the deficiencies until they were pointed out during the survey.
Failure to Secure and Properly Store Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, and that only authorized personnel had access to these medications. Multiple residents were found with medications at their bedside, including prescription and over-the-counter drugs, despite facility policy and staff statements indicating that residents were not permitted to self-medicate. These observations were made during interviews and direct observation of the residents and their rooms. One resident with a history of sepsis, hypertension, and chronic obstructive pulmonary disease was observed with a nebulizer and an ampule of Ipratropium-Albuterol Inhalation Solution at her bedside. The resident self-administered a breathing treatment, stating that she usually kept the ampule in her pocket. The nurse confirmed that the resident was not allowed to self-medicate and that nursing staff were responsible for administering such treatments due to the need for monitoring and potential side effects. Other residents were found with various medications at their bedsides, including medicated ointments, eye drops, antacids, magnesium hydroxide, and vitamins. Some of these residents were moderately cognitively impaired, and their care plans did not authorize self-administration of medications. The facility's policy required all drugs and biologicals to be stored securely and only accessible to authorized staff. The administrator confirmed that no residents in the facility were permitted to self-medicate and that nursing staff were responsible for medication administration and monitoring. Despite this, medications were found unsecured in resident rooms, and staff interviews confirmed that these practices were not in line with facility policy.
Failure to Complete and Document Nursing Admission Assessment
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, nursing staff did not document the admission nursing assessment for a female resident with multiple complex diagnoses, including cerebral infarction, acute respiratory failure with hypoxia, diabetes, hematemesis, lack of coordination, gait abnormalities, hyperlipidemia, epilepsy, and COPD. The resident was moderately cognitively impaired and required assistance with personal care. The physician completed an admission physical assessment, but the nursing admission assessment was missing from the electronic record. During interviews, the resident reported not recalling being seen or checked by a doctor after admission and believed she did not receive her diabetes, insulin, or seizure medications during the first days of her stay. The Administrator, who is also an RN, confirmed that the nursing admission assessment was not completed or found in the electronic record, explaining that the admitting nurse had to leave due to a family emergency, and the Administrator and ADON took over. The Administrator verified physician orders and entered medications but acknowledged the absence of the required nursing assessment, which is used to develop the resident's care plan.
Improper Storage of Nebulizer Equipment Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for a resident who required nebulizer breathing treatments. Observation revealed that the resident's nebulizer mask and tubing were left resting on the nightstand and not stored in a bag when not in use, contrary to facility protocol. The resident, who had a history of sepsis, hypertension, and chronic obstructive pulmonary disease, was observed self-administering a breathing treatment using equipment that had not been properly stored. The resident also had moderate cognitive impairment, as documented in her most recent assessment. Interviews with nursing staff and the facility administrator confirmed that the nebulizer mask and tubing should have been stored in a plastic bag to prevent contamination and that failure to do so was a break in infection control procedures. Staff acknowledged that the equipment was not stored as required and that the resident was not supposed to self-medicate. The administrator further confirmed that the improperly stored equipment would need to be discarded due to the lapse in infection control.
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, as required by regulatory standards. For one resident admitted with multiple diagnoses including urinary tract infection, sepsis, diabetes, chronic kidney disease, hypertension, and myocardial infarction, the admission MDS assessment triggered several care areas such as ADL functional/rehabilitation potential, urinary incontinence, nutritional status, dehydration/fluid maintenance, and pressure ulcer. However, the resident's care plan did not address any of these areas and was only focused on activities. The comprehensive care plan was completed late, beyond the required timeframe, and did not include the necessary care areas as identified by the MDS assessment. Another resident, with a history of hemiplegia, chronic heart failure, schizoaffective disorder, and acute respiratory failure, was found to be using smokeless tobacco in their room. The quarterly MDS assessment indicated moderate cognitive impairment, but the comprehensive care plan did not include any focus area for the use of smokeless tobacco. Staff, including the RN and DON, were unaware of the resident's tobacco use, and the omission was attributed to a possible oversight during a recent discharge and readmission. Facility policy requires that care plans incorporate identified problem areas and associated risk factors, which was not followed in this case. A third resident, diagnosed with Alzheimer's disease and chronic kidney disease, had a severely impaired cognition score on the admission MDS. The care plan for this resident only addressed participation in group activities and code status, omitting all other care areas triggered by the MDS, such as dental, discharge plans, diet, medication, specialized equipment, behaviors, or ADLs. Both the MDS nurse and DON confirmed that the comprehensive care plan was incomplete and not updated within the required timeframe after the resident's return from the hospital, as mandated by facility policy.
Improper Storage of Clean Dishware and Cleaning Equipment
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the kitchen, specifically in the storage and handling of clean dishware and cleaning equipment. During observation, clean plastic and ceramic mugs were found stored face-down on wet trays without the use of air-drying nets, preventing proper air-drying as required by facility policy. The Dietary Manager confirmed that air-drying nets were missing and acknowledged the importance of air-drying to prevent the accumulation of germs and bacteria. The facility's own warewashing policy required all dishware to be air-dried and properly stored, which was not followed in this instance. Additionally, a soiled mop and broom were observed stored head-side down inside a plastic storage crate in the utility closet, rather than being hung upright to allow for proper drying. The Dietary Manager stated that the mop should have been stored on a hook to ensure it dried properly and did not harbor bacteria. The facility's cleaning policy required cleaning tools to be maintained in a clean, odor-free condition and for mop buckets and wringers to be washed and stored inverted for drainage. These practices were not followed, as confirmed by direct observation and staff interview.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not following proper hand hygiene and glove-changing protocols during resident care. Specifically, while providing colostomy care to a resident with Alzheimer's disease, ileostomy status, and other comorbidities, an LVN touched the privacy curtain with gloved hands and did not change gloves or sanitize hands before starting the procedure. The LVN acknowledged not realizing the risk of cross-contamination, despite having received infection control training within the year. In another instance, a resident with chronic kidney disease, aphasia, diabetes, hemiplegia, and pressure ulcers received wound care from an LVN who also touched the privacy curtain with gloved hands and failed to change gloves or sanitize hands before beginning wound care. The LVN admitted she should have changed gloves and washed her hands, recognizing the curtain as a contaminated surface. This resident also received incontinent care from a CNA who did not change gloves or sanitize hands during the entire care process, including after cleaning the genital area and before handling a clean brief. The CNA stated he did not think glove changes were necessary, despite having received infection control training. Interviews with the Director of Nursing confirmed that staff are expected to change gloves after touching environmental surfaces like privacy curtains and during care to prevent cross-contamination. Facility policy on hand hygiene requires handwashing or sanitizing before and after direct resident contact, after contact with objects in the resident's vicinity, and when moving from contaminated to clean body sites. These observed failures to follow established infection control protocols were documented during surveyor observations and staff interviews.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
A Licensed Vocational Nurse (LVN) failed to ensure personal privacy for a resident during wound care. Specifically, on 06/10/2025, the LVN did not completely close the privacy curtain while providing wound care to a resident with multiple medical conditions, including chronic kidney disease, aphasia, type 2 diabetes mellitus, hemiplegia, hyperlipidemia, hypertension, and major depressive disorder. The resident was cognitively moderately impaired, always incontinent, and required extensive assistance with activities of daily living. During the wound care, the resident's buttocks area was exposed, and the end of the bed was completely uncovered, making the resident visible to anyone entering the room. The LVN acknowledged during an interview that the privacy curtain was not fully closed and confirmed awareness of the resident's right to privacy. The Director of Nursing (DON) also confirmed that privacy should have been provided during nursing care and that staff had received training on resident rights. Review of the facility's policy indicated that residents are guaranteed privacy and confidentiality under federal and state laws.
Failure to Accurately Document Resident Tobacco Use in Assessment
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their current tobacco use. Review of the resident's significant change Minimum Data Set (MDS) assessment showed that tobacco use was marked as 'No,' despite the resident actively using smokeless tobacco. The resident's care plan also did not include any focus area regarding tobacco use. During observation, multiple cans of smokeless tobacco were found at the resident's bedside, and the resident confirmed ongoing use since admission. Interviews with nursing staff and the Director of Nursing (DON) revealed they were unaware of the resident's tobacco use, and the DON acknowledged the inaccuracy in the MDS assessment, attributing it to the assessment being completed by an interim corporate RN. The resident in question had a history of hemiplegia and hemiparesis following a stroke, chronic heart failure, schizoaffective disorder bipolar type, and acute respiratory failure with hypoxia. The resident demonstrated moderate cognitive impairment, as indicated by a BIMS score of 9/15. Despite these complex medical needs, the assessment process failed to capture the resident's tobacco use, as required by the Resident Assessment Instrument User's Manual, which specifies that all forms of tobacco use must be documented if used during the 7-day look-back period.
Failure to Refer for Level II PASRR After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II Pre-Admission Screening and Resident Review (PASRR) following a new diagnosis of schizoaffective disorder, bipolar type. The resident, who had a history of hemiplegia, chronic heart failure, and moderate cognitive impairment, was admitted and later readmitted to the facility with no initial indication of a serious mental disorder according to the original PASRR Level I evaluation. However, subsequent medical records showed a new diagnosis of schizoaffective disorder, bipolar type, and the resident was prescribed antipsychotic medication for this condition. Despite the new diagnosis, there was no documentation of a referral to the local mental health authority for a Level II PASRR evaluation, as required when a significant change in mental health status occurs. The Director of Nursing confirmed that the diagnosis should have triggered a referral, but the corporate MDS coordinator, who identified the diagnosis in the absence of the facility's MDS coordinator, did not inform the facility or submit the necessary H&HS Form 1012. Facility policy required coordination with the PASRR program for individuals with mental disorders, but this process was not followed in this case.
Care Plan Not Updated to Reflect Resident's Refusal of Weight Monitoring
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for a resident with multiple complex medical conditions, including cerebral infarction, cerebral palsy, schizophrenia, epilepsy, and dysphagia. The resident had severely impaired cognition, was incontinent, and completely dependent on staff for all activities of daily living. Despite documented refusals by the resident to be weighed, this behavior was not reflected in the comprehensive care plan, even though the care plan included interventions related to weight monitoring due to a history of unplanned weight loss. Staff interviews and record reviews revealed that the process for documenting refusals involved CNAs noting the refusal in the EHR, which should have triggered further documentation by nursing staff and the MDS nurse in the care plan. However, this process was not followed, resulting in the resident's refusal to be weighed not being incorporated into the care plan. The facility's policy required that the care plan reflect the resident's expressed wishes regarding care, but this was not done, and the omission was acknowledged by the DON and MDS nurse during interviews.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive respiratory care in accordance with professional standards. The resident, who was nonverbal and required extensive assistance with all activities of daily living, had diagnoses including anoxic brain damage, contractures, aphasia, and dysphagia. Physician orders and the care plan specified that sterile tracheostomy care was to be provided every shift to prevent infection. During an observation, an RN performed tracheostomy care but broke sterile technique by placing non-sterile items on the sterile field and repeatedly crossing the sterile field with non-sterile parts of her arms while reaching for supplies. The RN acknowledged breaking the sterile field but was unaware of doing so at the time, despite having received training in tracheostomy care and infection control within the year. The DON confirmed that sterile technique was required for tracheostomy care and that the RN's actions constituted a breach of sterile field. Facility policy and professional standards reviewed also emphasized the importance of maintaining a sterile field during such procedures.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain sterile technique while providing tracheostomy care to a resident. During the observed procedure, the RN placed the sterile field on a side table and positioned non-sterile items, including a box of normal saline and gauze, on top of the sterile field. Each time the RN reached for these supplies, the non-sterile part of her arms crossed over the sterile field, resulting in a break of sterile technique. The RN confirmed during an interview that she was unaware she was breaking the sterile field, despite having received training in tracheostomy care and infection control within the year. The resident involved had significant medical needs, including anoxic brain damage, contractures, aphasia, and dysphagia, and was non-verbal and dependent on staff for all activities of daily living. The resident's care plan and physician orders required sterile tracheostomy care to prevent infection. Facility policy and professional standards specify the maintenance of a sterile field during such procedures. Despite annual competency checks indicating the RN was qualified, the observed failure to maintain sterility during tracheostomy care constituted a deficiency in ensuring staff competency and adherence to professional standards.
Failure to Label and Date Food Items in Resident Refrigerator
Penalty
Summary
The facility failed to implement its policy regarding the labeling and dating of food items brought in by family or visitors and stored in a resident's personal refrigerator. During an observation and interview, it was found that a resident's refrigerator contained several food items, including a covered plastic container with cooked sausage, a disposable bowl with canned peaches, a peanut butter and jelly sandwich, and two pieces of bread, none of which were labeled or dated as required by facility policy. The only exception was the sandwich, which was labeled with the resident's name but not dated. The resident was unable to recall how long the food had been stored in the refrigerator. The Director of Nursing (DON) confirmed that food in residents' refrigerators should be labeled and dated, and acknowledged that failure to do so could result in residents consuming spoiled or old food. The DON also stated that staff are responsible for checking the labeling and dating of food during advocate rounds, but noted that sometimes residents refuse to allow staff to open their refrigerators. Review of the facility's policy confirmed the requirement for labeling, dating, and monitoring food items stored in residents' refrigerators.
Failure to Maintain Effective Pest Control Program for Gnats
Penalty
Summary
The facility failed to maintain an ongoing and effective pest control program on the West hall, as evidenced by the presence of 11-12 small flying black insects resembling gnats observed on a side table in a resident's room during care. Staff interviews confirmed that the presence of these insects was a recurring issue, with reports made to housekeeping each time the problem was noted. The Director of Nursing acknowledged the ongoing issue with live insects in the room and stated that efforts were being made to address it, including plans to change pest control providers. The Maintenance Supervisor reported that the pest control company was contracted to visit every other week and as needed, with staff reporting pest sightings to housekeeping, who then informed him. He was aware of the gnat problem and stated that the pest control company had visited the same day, but indicated that gnats and flies were difficult to treat due to underlying sanitary issues, specifically noting that the resident urinated throughout the room and into the AC vent. Review of service logs showed that the pest control company had recently treated for roaches and ants, but not for gnats. The facility's pest control policy required an ongoing program to keep the building free of insects and rodents.
Dumpster Lacked Required Drain Plug for Sanitary Refuse Disposal
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that Dumpster #1 had a drain plug in place. During observation, it was noted that the dumpster was missing its drainage plug, and both the Dietary Manager and Maintenance Director confirmed they were unaware of the missing plug until the time of the survey. The Maintenance Director stated that the previous dumpster did not require a drain plug, but acknowledged that the current one did. Facility policy requires that garbage and refuse containing food waste be stored in a manner inaccessible to pests, and that outside dumpsters be kept closed and free of litter. Review of the Food Code also specifies that drains in waste receptacles must have drain plugs in place.
Failure to Accurately Document and Reconcile Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that drug records were accurately maintained and that an account of all controlled drugs was periodically reconciled for a resident receiving Hydromorphone, a Schedule II controlled substance. Record reviews revealed discrepancies between the narcotic reconciliation log and the Medication Administration Record (MAR), including missing signatures, doses signed out on the reconciliation log but not documented on the MAR, and doses administered but not signed out or documented. Specifically, there were instances where multiple 1mL doses of Hydromorphone were either not recorded on the MAR or not signed out on the reconciliation log, resulting in an 18mL discrepancy in the medication count. The resident involved was a female with a history of cerebral infarction, hypertension, epilepsy, and high cholesterol, who was severely cognitively impaired and received scheduled pain medication. The care plan indicated the need for analgesic medications as ordered, with monitoring for efficacy and adverse reactions. Despite this, the documentation for Hydromorphone administration was inconsistent, with some doses being signed out by one nurse but not reflected in the MAR, and other doses neither signed out nor documented as administered. Interviews with nursing staff revealed that one nurse began signing for missing doses on the reconciliation log and instructed another nurse to have additional staff sign blank spaces to correct the count. However, the nurse who was asked to sign refused, stating he had not administered those doses and reported the discrepancy to management. The administrator confirmed that the nurse had signed blank spaces on the log and had asked others to do the same, which was acknowledged as improper documentation. Facility policy required immediate documentation of medication administration and shift-to-shift controlled substance counts, but these procedures were not followed in this instance.
Failure to Maintain Accurate Medical Records for Oxygen and Respiratory Therapy
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was administered supplemental oxygen via nasal cannula, CPAP, and BiPAP without a corresponding physician's order. The resident, a male with multiple diagnoses including cellulitis, peripheral vascular disease, congestive heart failure, Type II diabetes, and morbid severe obesity with alveolar hypoventilation, was admitted with hospital discharge instructions for supplemental oxygen and CPAP use. However, upon review, there were no physician's orders for these treatments in the resident's consolidated orders or treatment administration records. Nursing progress notes documented the administration of oxygen at various flow rates and the use of CPAP and BiPAP, but these interventions were not supported by written or signed physician orders in the resident's medical record. Interviews with nursing staff revealed that they typically relied on physician orders or would contact the physician if an order was missing, but in this case, the need for an order was overlooked. The Director of Nursing and the Administrator both acknowledged that the process for transcribing and obtaining physician signatures for verbal or telephone orders was not followed as required by facility policy. Facility policies reviewed indicated that verbal and telephone orders must be promptly documented, transcribed into the resident's medical record, and countersigned by the physician during their next visit. In this instance, the failure to properly document and obtain physician authorization for the administration of oxygen therapy and respiratory support devices resulted in incomplete and inaccurate medical records for the resident.
Inoperable Call Light System in Resident's Room
Penalty
Summary
The facility failed to ensure an adequate communication system for residents to call for staff assistance, specifically in one of the rooms on the PCC hallway. The call light system in the room of a resident with a history of falls and requiring moderate assistance with activities of daily living was not functioning. This deficiency was identified through observation, interview, and record review, revealing that the call light did not produce a visible or audible signal when engaged. The resident, who has intact cognition and uses the call light to request nursing assistance, was unaware of the malfunction. The Maintenance Director and an LVN were also unaware of the issue until it was brought to their attention during the survey. The facility's policy requires that call lights be plugged in and operational at all times, highlighting a lapse in adherence to this policy.
Inoperable Light and Heater in Shower Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in the West Hall Downstairs. Specifically, the overhead light in the unmarked resident shower room on the right side of the hallway was not operable, and the overhead ceiling heater in the unmarked resident shower room on the left side of the hallway was also not functioning. These deficiencies were identified during an observation conducted with the Maintenance Director and the Assistant Director of Nurses (ADON-A). During the observation, it was noted that the light switch for the 5x2 ft ceiling light did not activate the light, and the on/off switch for the 1 ft circular ceiling heater did not activate the heater. In an interview, the Maintenance Director stated he was unaware of these issues and acknowledged that diminished lighting could affect resident safety. The ADON-A also stated she was unaware of the inoperable light and heater, agreeing that the lack of lighting could impact safety. A review of the facility's Maintenance Service policy from December 2009 indicated that buildings, grounds, and equipment should be maintained in a safe and operable manner at all times.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and adequate supervision for a cognitively impaired resident, leading to an elopement incident. The resident, diagnosed with dementia and severe cognitive impairment, was able to leave the facility unsupervised through an unknown door. Despite being identified as at risk for elopement, the resident was not adequately monitored, resulting in his absence being noticed only after he missed a medication pass. Interviews with staff revealed that the facility had multiple exterior doors, some of which could be easily disabled by staff, potentially allowing residents to exit unnoticed. The facility's front door was unlocked during weekdays and monitored by a receptionist, but other doors had alarms that could be disabled by staff. The facility's administrator and director of nursing were unaware of which door the resident used to elope, and the facility's camera system was not reviewed due to the administrator's lack of access. The resident was found at a local hospital the following day, having been brought in for disorientation, dehydration, and intoxication. Staff interviews indicated a lack of awareness and communication regarding the resident's elopement risk, with no clear procedures in place to identify residents who should not be allowed to sign themselves out. The facility's policy on wandering and elopements was not effectively implemented, contributing to the resident's unsupervised departure.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to post the results of the most recent survey in a location that was readily accessible to residents, family members, and legal representatives. On 09/04/2024, during a facility tour, it was observed that there was no survey results binder or sign indicating the location of the survey results posted anywhere in the facility. Interviews with staff revealed confusion about the location of the survey results book, with the receptionist initially unsure of its whereabouts and later finding it in the Medical Records office. The administrator acknowledged that the facility was undergoing an administrative transition, which contributed to the difficulty in locating the survey results book. Further interviews revealed that the facility staff were not certain if there was a policy in place to ensure the survey results were accessible, although they were aware of the regulatory requirement. The Director of Nursing mentioned that the survey book had been moved during a facility renovation and that the staff had trouble locating it after the previous administrator left. The facility's policy, revised in April 2017, stated that survey reports and plans of correction should be readily accessible and kept in a visible site, which was not adhered to in this instance.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. CNA A entered the kitchen without wearing a hair net, which is against the facility's policy and training. The absence of hair nets in the wall-mounted container outside the kitchen entrance was noted, indicating a lack of available supplies for staff compliance. Dietary Aide A noticed CNA A's non-compliance and asked her to leave the kitchen, highlighting the importance of wearing hair nets to prevent hair from contaminating food and drinks. Interviews with the Dietary Manager, Dietary Aide A, and CNA A confirmed that staff had been trained on the necessity of wearing hair nets in the kitchen. The Dietary Manager emphasized that it was mandatory for all employees to wear hair nets, and non-dietary staff were expected to ring a bell for assistance rather than entering the kitchen. The Director of Nursing (DON) reiterated the expectation that only dietary staff should enter the kitchen and stressed the importance of hair nets in preventing cross-contamination. The facility's policy on staff attire also required hair to be confined in a hair net or cap.
Failure to Post Detailed Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the actual hours worked by registered nurses, licensed practical or licensed vocational nurses, and certified nurse aides per shift in a prominent place. On two observed days, the posted documents only reflected the total number and type of licensed staff scheduled for a 24-hour period without breaking down the information per shift. This lack of detailed staffing information was observed on 07/15/2024 and 07/16/2024, where the documents were posted in a location that was not easily accessible or visible to residents, their families, and facility visitors. Additionally, on 07/17/2024, the nurse staffing document was posted next to the facility staff clock-in machine on a side hall wall, which was not in an area frequented by residents or visitors. The Director of Nursing (DON) confirmed that the staffing information was posted in this manner based on the format used since she started her position in March 2024. The facility's policy required direct care daily staffing numbers to be posted for every shift, but the current practice did not comply with this requirement, potentially limiting access to important staffing data for residents and visitors.
Failure to Report Suspected Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that allegations of abuse were reported immediately, as required by federal regulations. On 05/31/2024, two CNAs, identified as CNA B and CNA C, did not report a suspected case of abuse involving a resident. The resident, who had severe cognitive impairment, was observed by the CNAs to have a discharge that they believed to be semen. Despite their suspicions, neither CNA reported the incident to the charge nurse or the facility's abuse coordinator immediately. The CNAs' inaction was compounded by their uncertainty and lack of immediate response. CNA B, who noticed the discharge during a brief change, did not report it immediately because she was unsure of what she was seeing. Instead, she waited until the end of her shift to discuss it with CNA C, who also failed to report the incident promptly. Both CNAs attempted to contact the facility's abuse coordinator and other staff members but did not succeed in reaching them until the following morning. This delay in reporting the suspected abuse violated the facility's policy and federal requirements for immediate reporting. The facility's administrator and DON were eventually informed of the allegation and took steps to investigate. However, the initial failure to report the suspected abuse in a timely manner could have placed the resident at risk. The facility's policy clearly stated the need for immediate reporting of any suspected abuse, yet the CNAs did not adhere to this protocol, highlighting a significant deficiency in the facility's handling of abuse allegations.
Deficiencies in Food Storage, Labeling, and Kitchen Sanitation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, it was observed that there were 10 slices of bread and a box of 400 coffee creamers in the refrigerator that were not labeled or dated. Additionally, an ice cream freezer had an internal temperature of 70 degrees, causing 20 4-ounce packets of ice cream to melt. In the storeroom, three boxes of 3-gallon containers of apple juice concentrates were also found without labels or dates. Furthermore, a bag of 12 waffles in an outside freezer was not labeled or dated. The ceiling vent across from the dish machine had visible dirt and grease on the vent slats, and a dietary aide was observed not wearing a hair restraint while in the kitchen. Interviews with the Dietary Manager and Maintenance Director revealed that the importance of labeling and dating food, maintaining proper equipment functionality, and ensuring kitchen sanitation were acknowledged but not adhered to. The Dietary Manager confirmed the necessity of labeling and dating food to monitor its freshness and the importance of a clean dish machine ceiling vent for kitchen sanitation. The Maintenance Director was unaware of the malfunctioning ice cream freezer and the dirty ceiling vent, indicating a lapse in regular maintenance checks. The facility's policies and FDA Food Code requirements were not followed, leading to these deficiencies in food safety and sanitation practices.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of numerous flies in a resident's room on Hall 100 and in the Main Dining Room. In Resident #46's room, flies were observed landing on the resident, who expressed frustration and stated that the flies were a daily nuisance. In the Main Dining Room, flies were seen near a trash can and on Resident #53's food and drink, which was confirmed by the facility's Marketer during an interview. The Administrator acknowledged that the facility should be free of pests and provided documentation of pest control services, which indicated that the facility was serviced three times in April. However, the presence of flies persisted, indicating that the pest control measures were ineffective. The facility's policy on pest control, revised in May 2008, states that the facility should maintain an effective pest control program, which was not achieved in this instance.
Failure to Include Residents in Care Plan Development
Penalty
Summary
The facility failed to ensure residents and/or their representatives the right to participate in the development and implementation of their person-centered care plans. This deficiency was identified for four residents who were reviewed for care plans. The facility did not invite or include the input of these residents or their representatives as members of the interdisciplinary team in Care Plan Conference meetings. Resident #20, a [AGE] year-old female with severe cognitive impairment and multiple medical conditions, had a care plan that did not include information about the date or time of the Care Plan Conference meeting, who was invited, or who attended. A family member of Resident #20 stated they had not been informed of any care plan meetings and expressed concerns about the resident's physical decline and new wounds that were not communicated to them. Resident #8, a [AGE] year-old male with moderate cognitive impairment, stated he did not know what a care plan meeting was and had not been invited to one. Resident #3, a [AGE] year-old female with intact cognition, also stated she had not been invited to any care plan meetings and expressed interest in attending such meetings. Resident #29, a [AGE] year-old male with moderate cognitive impairment, could not recall ever being included in a care plan meeting. Interviews with facility staff revealed inconsistencies and gaps in the care plan conference process, with some staff members acknowledging that care plan meetings were not conducted correctly in the past and that improvements were being made recently.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident #46's care plan did not include information about the resident's broken and missing teeth, despite the resident's intact cognition and the visible condition of their teeth. The resident confirmed that the facility had not offered dental care. Resident #53's care plan was incomplete, lacking details about the resident's diet, need for assistance with activities of daily living, and discharge plans. The care plan also contained incomplete sentences, which could lead to inadequate care. Resident #53 had moderately impaired cognition, which further necessitated a detailed and complete care plan. Resident #85's care plan was also found lacking, as it did not address the resident's diet, advance directive, wounds, medication, need for assistance with activities of daily living, specialized medical equipment, or discharge plans. This resident had moderately cognitive cognition and multiple medical conditions, including Peripheral Vascular Disease and Chronic Kidney Disease, which required a comprehensive care plan. The MDS Coordinator confirmed these deficiencies and acknowledged that the absence of such information could lead to shortfalls in care. The facility did not have a dedicated MDS/Care Plan Coordinator at the time, relying on temporary assistance from an external coordinator.
Failure to Perform and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that Resident #20 received weekly skin assessments as ordered by the physician. Resident #20, a [AGE] year-old female with severe cognitive impairment and multiple medical conditions including type two diabetes mellitus and morbid obesity, had a physician's order for weekly skin assessments starting from 2/23/2024. However, the facility's records showed inconsistencies in the documentation of these assessments, with only three documented assessments on 1/12/2024, 3/18/2024, and 4/22/2024, despite the treatment administration record indicating that assessments were checked off weekly by various staff members. This discrepancy suggests that the assessments were either not performed or not properly documented, leading to a failure in monitoring the resident's skin condition effectively. This was further evidenced by the discovery of new wounds on Resident #20's shin, which were not communicated to the family in a timely manner. Interviews with staff revealed a lack of consistent practice in performing and documenting weekly skin assessments, particularly for residents without known skin issues. The Assistant Director of Nursing (ADON) admitted to only checking assessments for residents with known wounds, and the Director of Nursing (DON) acknowledged the risk of missed or delayed assessments and interventions. The facility's policies on charting, documentation, and skin assessment were not adequately followed, contributing to the deficiency in care for Resident #20.
Failure to Ensure Resident Environment Free from Accident Hazards
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. Resident #68 was observed in the dining room with a package of cigarettes and a cigarette lighter, which were placed on a table within reach of other residents. The Administrator confirmed that these items should not have been present. Additionally, Resident #87 was observed in the courtyard with a package of cigarettes, a cigarette lighter, and a pair of scissors, with no staff present. Although Resident #87's Smoking Assessment indicated he was safe to smoke without supervision, the presence of sharp objects was not addressed. Further observations revealed that a storage room on Hall 100, marked 'Clean Linen,' was open and unlocked, containing razors and other bathing supplies. Similarly, a shower room on Hall 100 was found open and unlocked, containing razors, shaving cream, and other supplies. The Administrator confirmed that these items should have been secured and that the potential for injury existed, even though no accidents had been reported. The facility's policy aimed to make the environment as free from accident hazards as possible, but these observations indicated a failure to adhere to that policy.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for four residents who required oxygen therapy. For Resident #3, the facility did not have proper orders in place to manage her supplemental oxygen support devices. Additionally, the facility did not ensure that her oxygen tubing was changed as needed, leading to the resident using discolored and potentially contaminated nasal cannula. Resident #3 expressed dissatisfaction with the lack of timely changes to her oxygen equipment, which she felt should not require her to request it explicitly. For Residents #12, #42, and #63, the facility failed to change the oxygen humidifier bottles when they were empty, as per the physician's orders. Observations revealed that the humidifier bottles for these residents were empty and had not been changed for several weeks. Resident #42 reported experiencing dry nasal passages and stated that their complaints were not addressed by the nursing staff. The Director of Nursing (DON) acknowledged that the task of changing the humidifier bottles was assigned to the night shift, which was staffed by agency nurses who had neglected this duty. The facility's policy on respiratory therapy, which mandates changing pre-filled humidifier bottles when the water level is low, was not followed. The DON admitted that the oversight in changing the humidifier bottles posed a risk of dry nasal passages for the affected residents. The facility's failure to adhere to its own protocols and physician orders resulted in inadequate respiratory care for the residents, potentially increasing their risk of respiratory complications.
Failure to Ensure Safe and Sanitary Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in two residents' personal refrigerators. Observations revealed that the refrigerators contained food items, such as scrambled eggs with cactus and a thawed frozen meal, which were unlabeled and undated. These findings were confirmed by CNA B during interviews, who acknowledged the presence of the unlabeled and undated food items in the residents' refrigerators. During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON), it was confirmed that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent residents from consuming spoiled foods. The DON stated that the night shift nurses were responsible for overseeing this task, but it was not being monitored. A review of the facility's policy on foods brought by family/visitors revealed that perishable foods should be discarded on or before the use-by date, indicating a failure to adhere to the established policy.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by an overfilled sharps container in a resident's room. The resident, a [AGE] year old female with severe cognitive impairment and multiple medical conditions including diabetes mellitus, cerebral arteriosclerosis, and cerebral infarction, required total care and was always incontinent of bowel and bladder. During a blood sugar check, an LVN was unable to dispose of used sharp supplies in the overfilled sharps container, posing a risk of puncture and infection to staff and residents. Interviews with the LVN and the DON revealed that central supply was responsible for replacing sharps containers, but all nurses had access to the central supply room and could replace full containers themselves. The facility's policy stated that containers should be replaced when 75% to 80% full to prevent puncture injuries. The DON acknowledged the risk posed by the overfilled sharps container and confirmed her responsibility for overseeing infection control in the building.
Failure to Enforce Smoking Policies
Penalty
Summary
The facility failed to establish and enforce policies regarding smoking for residents. Residents were observed smoking in the facility courtyard and admitted to keeping their own cigarettes and lighters in their rooms, despite the facility's policy prohibiting this. The smoking assessments for these residents indicated they were safe to smoke independently, but the facility's policy clearly stated that residents with independent smoking privileges should not keep smoking materials in their possession. The Administrator confirmed that no residents were meant to keep cigarettes or lighters in their rooms, highlighting a lapse in policy enforcement.
Failure to Include Insulin Administration in Care Plans
Penalty
Summary
The facility failed to develop, implement, and revise comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. For Resident #43, the care plan did not include interventions, goals, or focus areas related to type 2 diabetes or insulin administration, despite the resident having active physician orders for insulin injections and a diagnosis of diabetes mellitus. The resident's quarterly MDS assessment indicated moderate cognitive impairment and a need for insulin administration, which was not reflected in the care plan reviewed on 3/29/2024. For Resident #55, the care plan was not revised to address insulin administration, even though the resident had a physician's order for Novolin insulin starting from 2/1/2024. The resident's quarterly MDS assessment showed intact cognition and a diagnosis of type 2 diabetes. Interviews with the DON and RN/MDS-E confirmed that insulin administration should have been included in the care plan to ensure all treatment interventions were noted. The facility's policy on care planning stated that care plans should be developed based on resident assessments and within specified timeframes, which was not adhered to in these cases.
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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