Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mira Vista Court during CMS and state inspections, most recent first.
Staff did not pause the feeding pump for a resident with a feeding tube when the head of the bed was lowered for incontinence care, despite knowing this was required to prevent aspiration. The resident, who was fully dependent and had a history of stroke with impaired swallowing, continued to receive tube feeding while flat, in violation of safe enteral feeding practices.
Two CNAs did not wear required PPE, specifically gowns, while providing incontinence care to a resident on Enhanced Barrier Precautions due to wounds and a feeding tube. Despite clear signage and facility policy mandating gown and glove use for such residents, the CNAs either forgot or did not fully understand the requirements, resulting in non-compliance with infection control protocols.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A CNA did not wear a gown while providing high-contact care to a resident on enhanced barrier precautions, despite facility policy requiring both gloves and gowns for such activities. The resident had multiple complex medical conditions, including a feeding tube and a stage 4 pressure wound. Staff interviews and policy review confirmed that proper PPE was not used during care, resulting in a breach of infection control protocols.
A resident's prescribed Hydrocodone was diverted by an agency LVN, who removed both the medication cards and count sheet from the medication cart. Despite existing procedures for shift-to-shift narcotic counts, the diversion was not detected until the resident returned from a hospital stay and requested pain medication, at which point the missing medication was discovered and reported.
A resident with severe cognitive impairment and multiple skin conditions received wound care from an LVN who improperly disposed of soiled dressings in a regular trash can instead of a biohazard bag, violating the facility's infection control policies. The LVN admitted to being distracted and unaware of specific training on proper disposal, while the ADON confirmed the expectation for using biohazard bags to prevent contamination.
A resident with severe cognitive impairment was inappropriately touched by another resident with a history of behavioral issues. The incident occurred when the male resident was observed with his hand under the gown of the female resident, who was unaware of the event. Despite the male resident's known history of inappropriate behavior towards staff, this was the first incident involving another resident, highlighting a deficiency in monitoring and protective measures.
A CNA in an LTC facility failed to treat three residents with respect and dignity. One resident, with paralysis, felt like a burden due to the CNA's rude behavior during care. Another resident, with cognitive impairment, was told to soil his brief instead of being assisted to the bathroom. A third resident, with severe cognitive impairment, experienced indifference from the CNA. The facility terminated the CNA following an investigation.
A facility failed to honor a resident's representative's request to refuse treatment from a PA. Despite the representative's instructions to cancel an orthopedic appointment, the resident was taken to the appointment and seen by the PA. Communication breakdowns among staff led to the failure to cancel the appointment, as the message was not effectively relayed to the appropriate personnel.
A resident with a Stage 4 pressure ulcer on her ankle did not receive consistent wound care as ordered by the physician. A photograph showed a dressing that was not changed as required, with loose sides and drainage. Staff interviews revealed that wound care was to be provided by any nurse when the Wound Care Nurse was unavailable, but the facility's records did not specify who performed the care, leading to inadequate treatment.
A resident with a g-tube was found with an outdated dressing, indicating a failure to change it daily as required. Interviews with staff, including LVNs and the DON, revealed inconsistencies in the responsibility for changing the dressing, and the facility's electronic monitoring system did not provide a record of the care. This placed the resident at risk of infection.
A resident with severe cognitive impairment and a history of falls was left unattended on the floor for over two hours due to inadequate supervision. Despite being on a fall prevention program, the resident was not checked on from early morning until nearly 8 am. Staff interviews revealed inconsistencies in monitoring frequency, particularly for high-risk residents, leading to the resident's prolonged time on the floor.
A resident with moderate cognitive impairment and skin conditions did not receive the prescribed arm sleeve to protect her skin, as ordered by the physician. Despite multiple observations of the resident without the sleeve, staff failed to document her refusals. This oversight was acknowledged by the nursing leadership, who emphasized the importance of adhering to physician orders and proper documentation.
A resident with limited range of motion due to cerebral infarction and spastic hemiplegia was not provided with necessary contracture management devices, such as rolled washcloths, as outlined in their care plan. Despite being observed multiple times without these devices, staff interviews revealed a lack of awareness and implementation of the required interventions, highlighting a failure in communication and coordination among the care team.
A resident with severe cognitive impairment and a history of seizures was found using a disposable razor unsupervised, posing a safety risk. Despite requiring assistance with daily activities, the resident had access to razors in his room. Staff interviews revealed that the resident should have been supervised during shaving, and razors should have been removed to prevent harm. The facility's policy emphasized the need for monitoring resident environments, but this oversight led to a deficiency.
A resident with severe cognitive impairment and diabetes was administered the wrong enteral nutrition formula, Jevity 1.2 instead of Glucerna 1.5, due to staff oversight. The error persisted over several days, with nursing staff failing to review and follow physician orders, placing the resident at risk for complications.
A facility failed to act on a Pharmacist Consultant's recommendation to obtain an informed consent form for a resident's anxiety medication, hydroxyzine. The resident, with diagnoses including Parkinson's disease and anxiety disorder, continued to receive the medication for several months without the necessary consent, despite the consultant's repeated recommendations.
A resident with moderate cognitive impairment and a skin condition had a physician's order to wear an arm sleeve daily, which was not consistently followed. Observations showed the arm sleeve was not in place, and the resident's skin was dry and flaky. Despite this, records inaccurately documented the arm sleeve as provided, with no indication of refusal. Interviews with nursing staff confirmed the resident often refused the sleeve, and documentation was not accurately maintained.
A facility failed to notify a physician when a resident with an indwelling catheter exhibited dark red urine, indicating possible hematuria. Despite the care plan's interventions, the issue was reported during a shift change but not documented or communicated to the physician. Staff interviews confirmed the oversight, highlighting a deficiency in preventing urinary tract infections.
A resident with osteomyelitis and a urinary tract infection missed two days of antibiotic therapy due to a failure in ordering medications on time. The LVN did not ensure the availability of antibiotics and normal saline, leading to missed doses. The facility's use of agency nurses and limited pharmacy runs contributed to the issue, and the facility's medication management policy was not fully followed.
Failure to Pause Enteral Feeding Pump During Bed Positioning
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding via a feeding tube was provided with appropriate care to prevent complications. Specifically, staff did not pause the resident's feeding pump when the head of the bed was lowered during incontinence care, despite the resident being completely dependent on staff for activities of daily living and having a history of stroke with impaired swallowing and speech. Observations confirmed that the feeding pump continued to infuse while the resident's head was lowered, contrary to established safe practices. Interviews with staff revealed that they were aware of the need to have a nurse pause the feeding pump before lowering the head of the bed, as not doing so could lead to aspiration. However, the responsible CNA admitted to not pausing the pump during care, citing being busy and the delay in waiting for a nurse. The facility's policy on gastrostomy tubes did not address the need to pause the pump when the bed was not elevated, and the deficiency was identified through direct observation, interviews, and record review.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to adhere to the facility's infection prevention and control program by not wearing the required personal protective equipment (PPE) while providing care to a resident on Enhanced Barrier Precautions. The resident, a male with a history of stroke, impaired swallowing and speech, and a feeding tube, was completely dependent on staff for activities of daily living and had wounds, necessitating Enhanced Barrier Precautions. Facility policy and posted signage required staff to wear gowns and gloves during high-contact care activities for residents with wounds or indwelling medical devices. However, video evidence and direct observation confirmed that two CNAs provided incontinence care to the resident without wearing gowns, despite the presence of PPE supplies and clear signage outside the resident's room. Interviews revealed that one CNA was unaware of the meaning of Enhanced Barrier Precautions, although she knew she was supposed to wear a gown and gloves when caring for the resident. She admitted to sometimes forgetting to wear a gown due to being busy and not always paying attention to posted signage. The Assistant Director of Nursing confirmed that staff were required to wear gowns and gloves for residents with artificial openings and that multiple in-services on infection control had been conducted. The facility's policy, dated 05/15/23, specified the use of Enhanced Barrier Precautions for residents with wounds or indwelling devices during high-contact care activities, such as changing briefs or assisting with toileting.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow the facility's infection prevention and control program by not wearing a gown while providing care to a resident on enhanced barrier precautions. The resident had multiple diagnoses, including diabetes, stroke, non-Alzheimer's dementia, hemiplegia, muscle wasting, cognitive communication deficit, and a feeding tube, as well as a stage 4 pressure wound. The resident's care plan required enhanced barrier precautions, including the use of gloves and gowns for high-contact care activities such as dressing, bathing, transferring, and wound care. During an observation, the CNA entered the resident's room, donned gloves but not a gown, and proceeded to remove the resident's boots to check skin integrity and reposition the resident in bed, both of which are considered high-contact activities under the facility's policy. Interviews with the CNA, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that staff are required to wear both gloves and gowns when providing care to residents on enhanced barrier precautions. The CNA admitted to not wearing a gown and stated she was told by another aide that it was not necessary if only checking on the resident. Facility policy, revised in May 2023, clearly states that enhanced barrier precautions require the use of gloves and gowns for residents with wounds or indwelling medical devices during high-contact care activities. The failure to adhere to these precautions was observed and confirmed through staff interviews and policy review.
Failure to Prevent Diversion of Controlled Substance by Agency Nurse
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of property, specifically the diversion of the resident's prescribed Hydrocodone 10/325 medication. The resident, a male with a history of anxiety disorder, depression, and diabetes mellitus, had a physician's order for Hydrocodone-acetaminophen to be administered as needed. The medication was properly received and added to the controlled substance count, but after the resident returned from a hospital stay, it was discovered that the medication and its count sheet were missing from the medication cart. On the day prior to the discovery, an agency LVN was observed to have spilled water in the narcotic drawer of the medication cart. The DON and MDS Coordinator conducted a narcotic count following this incident and found all cards and pills accounted for, including the resident's Hydrocodone. However, the next day, when the resident returned and requested pain medication, staff found that both the medication cards and the count sheet for the Hydrocodone were missing. The incident was reported to facility management, and an internal investigation confirmed that the medication had been diverted during the agency LVN's shift. Interviews with staff revealed that standard procedures required counting both the cards and pills for controlled substances at each shift change, and that any discrepancies were to be reported immediately. Despite these procedures, the medication was able to be removed without detection until the resident returned and the need for the medication was identified. The agency LVN suspected of diverting the medication did not respond to attempts to contact her after the incident.
Improper Disposal of Soiled Dressings During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper disposal of soiled dressings and gauze during wound care for a resident. The resident, an elderly male with severe cognitive impairment and multiple skin conditions, including a lymphademic wound and a Stage 4 pressure ulcer, was observed receiving wound care from an LVN. During the procedure, the LVN discarded soiled dressings and gauze in a regular trash can instead of a biohazard bag, which is against the facility's infection control policies. The LVN acknowledged awareness of the proper disposal procedure but attributed the oversight to being distracted by other staff. The Assistant Director of Nursing confirmed the expectation for staff to use biohazard bags for soiled dressings to prevent contamination and infection. Despite previous training on infection control, the LVN could not recall specific training on disposing of soiled wound dressings, highlighting a gap in adherence to infection control protocols.
Inappropriate Touching Incident Between Residents
Penalty
Summary
The facility failed to protect a resident from inappropriate touching by another resident, which constitutes a deficiency in ensuring residents' rights to be free from abuse and neglect. The incident involved a female resident with severe cognitive impairment and a male resident with severe cognitive impairment and a history of inappropriate behavior. The male resident was observed with his hand under the gown of the female resident, which was immediately addressed by staff. The female resident, who has Alzheimer's disease and requires maximum assistance with activities of daily living, was not aware of the incident and did not exhibit any signs of distress. The male resident, who has end-stage kidney disease, dementia, and a communication deficit, had a history of making inappropriate remarks and attempting to touch staff members. Despite this history, the male resident had not previously exhibited inappropriate behavior towards other residents. The facility's failure to prevent this incident highlights a lapse in monitoring and managing residents with known behavioral risks. The male resident's behavior was attributed to his dementia, which impaired his ability to understand appropriate conduct. The facility's records indicate that staff were aware of the male resident's behavioral issues, but the incident still occurred, indicating a deficiency in the facility's protective measures for residents.
Failure to Uphold Resident Dignity and Rights
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, as evidenced by the interactions between CNA A and three residents. Resident #1, a cognitively intact female with paralysis and a self-care deficit, reported that CNA A was rude and impatient during incontinent care, making her feel like a burden. Resident #2, a male with moderate cognitive impairment and mobility issues, stated that CNA A instructed him to soil his brief instead of assisting him to the bathroom and did not clean him properly afterward. Resident #3, a male with severe cognitive impairment and total dependence on staff, experienced indifference from CNA A when he asked for the time and when he used his call light multiple times. The facility's investigation revealed that CNA A denied the allegations and refused to accept responsibility for her actions. The Administrator decided to terminate CNA A due to her indifferent and rude behavior towards the residents. The facility's policy on Resident Rights, revised in 2017, emphasizes the importance of providing an environment that preserves dignity and contributes to a positive self-image, which was not upheld in these instances.
Failure to Honor Resident Representative's Medical Treatment Refusal
Penalty
Summary
The facility failed to honor the request of a resident's appointed representative to refuse medical treatment from a Physician's Assistant (PA). The resident, a female with severe cognitive impairment and multiple medical conditions, was scheduled for an orthopedic appointment. Despite the representative's explicit instructions to cancel the appointment and not to have the resident seen by a PA, the facility proceeded with the appointment. The representative had communicated the cancellation request to the facility's receptionist, who relayed the message to the nurse on duty. However, the message was not effectively communicated to the appropriate staff, resulting in the resident being taken to the appointment and seen by the PA. Interviews with the facility staff revealed a breakdown in communication. The receptionist confirmed receiving the cancellation request and passing it to the nurse, but the Director of Nursing (DON) stated that the message did not reach the weekday nurse responsible for the resident's care. Consequently, the resident was transported to the appointment without an escort and was examined by the PA, contrary to the representative's wishes. The facility's records showed no documentation of the cancellation request, and the administrator confirmed that the note was not received by the day and evening shift nurses.
Inadequate Wound Care for Resident with Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to provide necessary wound care treatment for a resident with a Stage 4 pressure ulcer on her left lateral ankle, as ordered by the physician. The resident, who was totally dependent on staff for all activities of daily living and had multiple pressure ulcers, did not receive consistent wound care. A photograph provided by the resident's family showed a dressing dated two days prior, which was loose and had reddish drainage soaked through, indicating that the dressing had not been changed as required. The Wound Care Nurse confirmed that the dressing should have been changed when it was noted to be loose or when drainage was present. Interviews with staff revealed that wound care was supposed to be provided by any nursing staff when the Wound Care Nurse was unavailable, following the physician's orders. However, the September Treatment Administration Record (TAR) only indicated that wound care was completed daily without specifying which nurse performed the care. The facility's policy required an evaluation with each dressing change, but it appears this was not consistently followed, leading to inadequate wound care for the resident.
Failure to Change G-Tube Dressing Daily
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a gastrostomy tube (g-tube). The resident, a female with a history of benign neoplasm of bones, unspecified dementia, dehydration, and dysphagia, was observed with a g-tube site dressing dated three days prior to the observation date. The facility's records indicated that the dressing should be changed daily, but this was not adhered to, as evidenced by the outdated dressing. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), the Director of Nursing (DON), and the Treatment Nurse, revealed inconsistencies in the responsibility and execution of changing the g-tube site dressing. The DON expected staff to check the dressing during medication administration, but the task was not completed as required. The facility's electronic health monitoring system, which tracks task completion, did not provide a record of the g-tube site care for the specified period, further indicating a lapse in care. This failure to change the dressing as per the physician's orders and facility policy placed the resident at risk of infection.
Resident Left Unattended on Floor Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to the resident being left on the floor for an extended period. The resident, an elderly female with severe cognitive impairment and a history of falls, was found on the floor multiple times since her admission. Despite being on a fall prevention program, the resident was not checked on from 05:15 am to 07:50 am, during which she lay on the floor next to her bed. Video observations confirmed that the resident was on the floor for over two hours without staff intervention. Interviews with staff revealed inconsistencies in the frequency of resident checks, particularly for those at high risk of falls. The Director of Nursing (DON) and other staff members acknowledged that the resident should have been monitored more frequently due to her frequent falls and inability to call for help. The facility's expectation was for staff to round on residents every two hours, but the resident's specific needs required more frequent checks, which were not consistently performed.
Failure to Follow Physician Orders for Arm Sleeve Application
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow physician orders to apply an arm sleeve to the resident's right arm, which was intended to protect the skin and prevent the resident from scratching herself. Despite the physician's order, the resident was observed multiple times without the arm sleeve, and there was no documentation of refusal by the resident. The resident, who had moderate cognitive impairment and a history of skin conditions, was observed with dry, flaky skin and a rash on her right forearm. Interviews with the nursing staff revealed that the resident often refused the arm sleeve, but the refusals were not documented as required. The Director of Nursing and Assistant Director of Nursing both acknowledged the importance of following physician orders and documenting any refusals, noting that failure to do so could lead to worsening of the resident's skin condition.
Failure in Contracture Management for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate contracture management for a resident with limited range of motion, specifically neglecting to apply rolled washcloths to the resident's left contracted hand. The resident, who has a history of cerebral infarction and spastic hemiplegia affecting the left side, was observed multiple times without any contracture management device in place, despite being care planned to use such devices. Interviews with the resident and staff revealed that the resident had not refused the intervention, and staff were either unaware or had not implemented the necessary measures. The care plan for the resident indicated the need for contracture management to prevent further decline in range of motion, yet observations and interviews confirmed that the intervention was not being carried out. Nursing staff, including an LVN and the ADON, acknowledged the importance of the intervention but failed to ensure its implementation. The Director of Therapy was unaware of the need for a washcloth or splint for the resident's hand, indicating a lack of communication and coordination among the care team. The DON confirmed that the nursing team was responsible for implementing the care plan interventions, which were not being followed, potentially leading to further loss of joint mobility.
Resident Access to Razors Poses Safety Risk
Penalty
Summary
The facility failed to maintain a safe environment by allowing a resident access to disposable razors, which posed a risk of accidents or injuries. The resident, a male with severe cognitive impairment and a history of seizures, was observed using a razor unsupervised in his room. Despite requiring assistance with activities of daily living due to general weakness and poor safety awareness, the resident was found with a package of razors on his bedside table. Interviews with staff revealed that the resident was supposed to be supervised during shaving, and razors should have been removed from his possession to prevent potential harm. Staff members, including a CNA and an LVN, acknowledged the risk associated with the resident having razors and stated that it was their responsibility to ensure razors were not left with residents. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the resident should not have had access to razors and emphasized the expectation for staff to monitor resident environments and remove any hazardous items. The facility's policy on accident and incident reporting highlighted the need for leadership to follow established guidelines, but the oversight in this case resulted in a deficiency related to accident hazards.
Failure to Administer Correct Enteral Nutrition Formula
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was administered the correct formula as per physician orders. The resident, who had severe cognitive impairment and a diagnosis requiring gastrostomy for nutritional support, was supposed to receive Glucerna 1.5 due to diabetes. However, observations revealed that the resident was being administered Jevity 1.2 instead. This discrepancy was noted over several days, with the feeding machine showing bottles of Jevity 1.2 dated incorrectly. Interviews with the nursing staff, including an LVN and the ADON, revealed a lack of awareness and adherence to the physician's orders. The LVN admitted to not reviewing the orders properly and acknowledged the mistake of administering the wrong formula. The ADON was also unaware of the error until it was brought to her attention and stated that the wrong formula was used due to a nurse grabbing the incorrect bottle. Both staff members recognized that not following the physician's orders could lead to abnormal blood sugar readings for the resident. The DON confirmed that the nursing staff is expected to follow physician orders and report any issues immediately. The facility's policies on physician orders and enteral feedings emphasize the importance of obtaining and following specific orders, including the brand and type of formula. The failure to adhere to these protocols placed the resident at risk for complications such as diarrhea and nausea, as well as potential blood sugar issues due to the incorrect formula being administered.
Failure to Act on Pharmacist's Recommendations for Medication Consent
Penalty
Summary
The facility failed to act upon drug regimen irregularities reported by the Pharmacist Consultant for a resident reviewed for medication regimen review. The Pharmacist Consultant recommended that an additional consent form for the resident's anxiety medication, hydroxyzine, be completed and uploaded to the resident's chart. Despite this recommendation, the consent form was not obtained until several months later, during which time the resident continued to receive the medication without the necessary informed consent. The resident, a male with a BIMS score indicating no cognitive impairment, had active diagnoses including Parkinson's disease, schizoaffective disorder, and anxiety disorder. The resident's care plan included goals and approaches for managing anxiety and monitoring for adverse drug reactions. However, the facility's failure to ensure the completion of the informed consent form for the psychoactive medication hydroxyzine was identified as a deficiency, as it could place residents at risk for adverse side effects and decreased quality of life.
Inaccurate Documentation of Arm Sleeve Use
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the use of an arm sleeve. The resident, a female with moderate cognitive impairment and a skin condition, had a physician's order to wear an arm sleeve daily to prevent scratching a rash on her right arm. However, observations on multiple occasions revealed that the arm sleeve was not in place, and the resident's skin was dry and flaky. Despite this, the treatment administration record inaccurately documented that the arm sleeve was provided, with no indication of refusal. Interviews with the nursing staff, including an LVN and the DON, confirmed that the resident often refused to wear the arm sleeve, preferring lotion instead. The LVN admitted to incorrectly documenting the administration of the arm sleeve and failing to note the resident's refusal. The DON and ADON emphasized the importance of accurate documentation and following physician orders, noting that failure to do so could lead to false documentation. The facility's policy requires that any refusal of treatment be documented, and the physician notified, which was not adhered to in this case.
Failure to Notify Physician of Hematuria in Resident with Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling catheter. The resident, an 89-year-old female, had a diagnosis of acute cystitis without hematuria and recurrent urinary tract infections. Despite the care plan's intervention to use enhanced barrier precautions and provide catheter care as ordered, the facility did not contact the physician when blood was observed in the resident's catheter bag. This observation was made during a shift change, and there was no documentation indicating that the physician had been notified of the hematuria. Interviews with staff revealed that the presence of dark red urine was reported during a verbal shift change, but no action was taken to notify the physician. The Licensed Vocational Nurse (LVN) acknowledged the need to inform the physician due to the potential risk of a urinary tract infection leading to sepsis. The Director of Nursing (DON) confirmed that the hematuria was reported at the end of a shift, and the oncoming nurse was expected to call the doctor and family, and flush the line. However, these actions were not documented or carried out, leading to a deficiency in the care provided to the resident.
Resident Misses Antibiotic Doses Due to Medication Ordering Lapse
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who missed two days of antibiotic therapy. The resident, an elderly female with osteomyelitis of the vertebrae, a urinary tract infection, and lumbar disc disease, was admitted to the facility with orders for intravenous antibiotics and normal saline flushes. However, due to a lapse in ordering these medications, the resident missed doses on two separate occasions. The deficiency occurred when LVN A did not order the necessary antibiotics and normal saline solution in time, resulting in the facility running out of these medications. On one occasion, the LVN discovered the absence of the medication and subsequently ordered it from the pharmacy, but it was not delivered until later that night. The LVN informed the physician about the missed dose but did not ensure the medication was available beforehand. Additionally, the facility's policy required the nurse to notify the physician, ADON, DON, the resident, and the resident's family if a medication was unavailable, which was not fully adhered to. Interviews with the ADON and DON revealed that the facility often used agency nurses, which contributed to the failure in ordering medications as per policy. The ADON noted that there was only one pharmacy run per day, and if orders were placed late, they would not be delivered until the next day. The DON emphasized that the nurse should have placed the order on hold, contacted the pharmacy for a stat delivery, and notified the physician and family about the missed dosage. The facility's policy on medication management required contacting the pharmacy and documenting accordingly if a medication was unavailable, which was not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
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| Garden Terrace Healthcare Center Of Fort Worth | 0.9 mi | ★★★★★ | 7 | 0 |
| Cityview Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 12 | 0 |
| Wedgewood Nursing Home | 1.3 mi | ★★★★★ | 16 | 0 |
| Ft. Worth Southwest Nursing Center | 1.5 mi | ★★★★★ | 6 | 0 |
| Ignite Medical Resort Fort Worth, Llc | 1.7 mi | ★★★★★ | 17 | 0 |
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