Northeast Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 603 Corinne St, San Antonio, Texas 78218
- CMS Provider Number
- 455754
- Inspections on file
- 41
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Northeast Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with a fragile, non–weight-bearing right knee stabilized by a knee immobilizer did not receive care consistent with professional standards to prevent skin breakdown. The facility failed to obtain detailed provider orders for immobilizer care, did not include the device in the care plan, and weekly skin assessments repeatedly documented that the resident had no brace and did not assess the skin under it. Staff reported using the immobilizer during bathing without removing or cleaning it, and the resident stated the brace was never removed or washed and developed a foul odor. A treatment nurse later noted new right thigh skin breakdown at the brace edges, and a NP identified stable skin breakdown and a possible resolved DTI, while medical providers indicated they expected periodic brace removal for hygiene and skin checks and had not been contacted for care instructions.
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident’s physician-ordered right knee immobilizer, despite documentation of a fragile right knee at admission and an order for the immobilizer to restrict movement. The care plan contained no focus, goals, or interventions for the device, and a CNA reported having no care plan instructions, relying instead on common sense and avoiding removal of the brace. The resident reported that staff never removed or cleaned the brace or checked the underlying skin, and that the brace developed a foul odor until a representative replaced it with one from home. The physician and a PA stated they expected specific orders and periodic removal of the immobilizer for skin assessment and hygiene, and the DON acknowledged that no orders or care plan interventions had been obtained or implemented for the immobilizer.
A resident admitted for orthopedic aftercare with a fragile right knee had a physician order and MDS documentation for a right knee immobilizer, and nursing notes also recorded the presence of the immobilizer. However, during multiple weekly skin assessments, an LVN documented that the resident did not have a brace, despite the resident wearing a right knee brace and a CNA confirming its use. The LVN later acknowledged recognizing the brace and attributed the incorrect entries to oversight, while facility policy and the DON’s statements required accurate medical records.
Two residents, one with legal blindness and moderate cognitive impairment and another with a healing leg fracture and intact cognition, were involved in an incident where a suspicious package containing a decorative cross and multiple baggies of a crystal-like substance suspected to be narcotics was delivered by a visitor posing as a family member. A nurse (RN) assisted a resident in retrieving and opening the package, discovered the suspected drugs, secured them, and notified the DON, the administrator, and law enforcement, who confiscated the substance. Both residents denied knowledge of drug involvement and described the package as a gift cross arranged through a contact associated with a former resident. The administrator conducted an internal investigation but, despite a facility abuse policy requiring alleged violations to be reported to the State Licensing Agency, did not report the incident to the State Survey Agency, resulting in a deficiency for failure to report an alleged violation within the required 24-hour timeframe.
A resident on blood thinners fell and hit her head, but staff failed to complete required neuro checks and did not consistently document or communicate the incident and follow-up care. There was confusion among staff about protocols for residents on anticoagulants after a fall, and the resident was found unresponsive hours after the last documented assessment, resulting in her death.
A resident's medical record was incomplete following a fall and a behavioral incident involving verbal aggression and a room change. Documentation was missing for the time and location of the fall, pain and skin assessments, physician orders for monitoring, and details of the behavioral event. Staff interviews confirmed that required assessments and interventions were not fully recorded in the EMR, contrary to facility policy.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact and required moderate assistance, was subjected to verbal abuse when an LVN told her to "shut up" during care. The incident was witnessed by another staff member, reported to a supervisor, and documented in facility records, confirming a failure to protect the resident from abuse as required by facility policy.
Two residents who required mechanical lift transfers did not have this intervention documented in their care plans, despite being dependent on staff for transfers. Staff were observed using mechanical lifts for both residents, but the care plans only referenced general assistance or use of mobility bars. Interviews with the MDS Coordinator and DON confirmed the omission, which was inconsistent with facility policy requiring comprehensive, person-centered care plans.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A resident with a stage 3 pressure ulcer did not have wound care dressing changes documented on the TAR for three days. An RN provided the wound care as ordered but failed to record it due to being busy, which was confirmed by both the RN and the DON. This lack of documentation was contrary to facility policy and accepted professional standards.
The facility failed to ensure proper storage of medications, as two residents were found with unauthorized medications at their bedsides, and a medication cart was left unlocked and unattended. A cognitively impaired resident had antacids, while another resident had hemp gummies and blood flow supplements, none of which were prescribed. An LPN left a medication cart unsecured, posing a safety risk. The DON confirmed that all medications should be stored securely.
The facility's kitchen operations were found deficient in food safety standards. A bag of whipped cream was undated in the fridge, and dry food items were stored on the floor. Additionally, the Dietary Supervisor failed to log temperatures for all food items before meal service, including alternate items. These actions could risk foodborne illness for residents.
The facility failed to maintain effective infection control, as evidenced by staff not adhering to protocols for Enhanced Barrier Precautions, hand hygiene, and glove changes. A staff member did not wear a gown for a resident on EBP, another did not change gloves during incontinent care, and an ADON failed to sanitize hands properly during wound care. These lapses increased the risk of cross-contamination and infection for the residents involved.
The facility failed to obtain consent for the use of wander guards on two residents identified as elopement risks. Both residents had cognitive impairments, and their families or representatives were not informed or involved in the decision-making process. The facility's policy did not require consent for wander guards, leading to a lack of communication and documentation, which risked unnecessary restriction of residents' freedom.
A facility failed to validate a resident's DNR due to a missing witness signature, resulting in the resident being treated as full code despite their or their legal guardian's wishes. The resident, with severe cognitive impairment and multiple medical conditions, had a care plan indicating DNR status, but the incomplete documentation rendered it invalid. Staff interviews confirmed the oversight, which was against the facility's policy to respect and document advance directives.
A facility failed to accurately assess a resident's urinary continence status, marking them as occasionally incontinent despite having an indwelling catheter. The resident, with a history of urinary issues and chronic kidney disease, was confused and unaware of the catheter. Staff confirmed the catheter's use since admission, and the MDS Coordinator admitted to the assessment error. The DON acknowledged the mistake, highlighting the MDS's role in care planning and billing.
The facility failed to identify mental illness in PASRR assessments for two residents with bipolar disorder, leading to potential gaps in necessary mental health services. Despite diagnoses and medication use, the PASRR screenings incorrectly marked 'No' for mental illness. Staff interviews revealed reliance on previous assessments without updates, and a misunderstanding of criteria for PASRR services.
A resident with moderate cognitive impairment was found with scissors, nail clippers, and a razor in his room, which he used for personal grooming. Facility staff acknowledged the risk of self-harm and the need for supervision, but the facility's policy on accident hazards was not provided.
The facility failed to provide adequate incontinent and catheter care for two residents, leading to potential infection risks. A resident's peri and catheter care were improperly conducted, with inadequate cleaning and failure to change gloves. Another resident's catheter bag was found on the floor, breaching infection control practices. These deficiencies highlight lapses in following facility protocols.
A resident with respiratory failure and COPD did not receive proper respiratory care due to unclean oxygen concentrator filters. The facility's staff, including the RN, Maintenance Director, and HR Manager, failed to maintain the equipment as per policy, leading to potential risks in oxygen delivery. The DON acknowledged the issue, highlighting a lack of oversight in equipment maintenance.
A facility failed to ensure proper communication and coordination with a dialysis clinic for a resident with end-stage renal disease. The Renal Dialysis Communication Forms were often incomplete or missing, and staff interviews revealed issues with obtaining necessary information from the dialysis clinic. This lack of communication hindered the facility's ability to monitor the resident's condition and respond to changes or recommendations from the clinic.
The facility failed to report two separate allegations of abuse involving residents to the state survey agency. In one case, a resident claimed a man hurt her, but the administrator did not investigate thoroughly or report it. In another incident, a resident allegedly hit another with a stick, but the incident was not reported. The administrator, responsible for abuse prevention, did not follow proper procedures, risking unreported abuse.
A resident with severe cognitive impairment reported being hurt by a man, but the facility's investigation was inadequate. The administrator, responsible for abuse prevention, did not conduct necessary interviews or assessments, concluding without evidence that an x-ray technician was involved. This failure to follow the facility's policy on abuse prevention could risk resident safety.
Two residents in a facility had inaccurate MDS assessments, with one resident's physical behavior incident not coded and another resident's discharge incorrectly coded as to Home/Community instead of a hospital. The errors were due to communication gaps and procedural oversights, as staff relied on progress notes for care. The facility's policy requires comprehensive assessments, but these incidents highlight lapses in following the policy.
The facility failed to post daily nurse staffing information for six days, with the last update dated before the staffing coordinator went on vacation. The ADONs were responsible for posting in the SC's absence, but the task was not completed. Interviews with the SC, DON, and OM revealed a lack of clarity about the responsibility for posting, though they believed the oversight did not impact resident care.
Failure to Monitor and Manage Knee Immobilizer Resulting in Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with professional standards to prevent pressure ulcers and skin breakdown related to a right knee immobilizer for one resident. The resident was admitted with a fragile right knee that had been reset by an orthopedic surgeon and stabilized with a knee immobilizer, and she was non–weight bearing with the brace intended to prevent dislocation. At admission and throughout the review period, there were no physician orders specifying care instructions for the knee immobilizer, including how and when to remove it, how to monitor its fit, or how to assess the skin under and around it. The only order present was a late entry directing that the right knee immobilizer be applied to restrict movement, and there were no new orders when skin breakdown was later identified. The resident’s care plan contained no focus, goals, or interventions related to the knee immobilizer, and weekly skin assessments repeatedly documented that the resident did not have a brace, despite her wearing a right knee immobilizer and having an existing right heel pressure ulcer. These assessments did not include evaluation of the skin under the immobilizer. Nursing documentation noted the presence of the immobilizer at admission but did not reflect ongoing monitoring or care of the device. The medication administration records for the relevant month showed no evidence of monitoring of the immobilizer and no wound care for the newly identified thigh wounds until several days after they were first documented. The resident reported that staff did not remove the brace to check her skin, did not wash the brace, and instead wrapped it in plastic during bathing, and she believed staff did not know how to care for it. She became concerned when the brace developed a foul smell, and her representative eventually replaced the original brace with one from home. The treatment nurse stated he recognized the brace from the start but did not remove it because the resident would not allow it; he only gently peeled back the edges weeks later, at which time he observed two new areas of skin breakdown on the right thigh attributed to rubbing from the brace. A nurse practitioner later assessed stable skin breakdown and a potentially resolved deep tissue injury under the thigh and expressed concern that the brace was ill-fitting and possibly too tight. Medical providers interviewed stated they expected periodic removal of the immobilizer for hygiene and skin assessment and that the facility had not contacted them for clarification or care instructions, and the DON acknowledged there were no orders or care plan interventions for the immobilizer and could not provide a policy for orthotic device care.
Failure to Care Plan and Implement Care for Physician-Ordered Knee Immobilizer
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident’s physician-prescribed right knee immobilizer. The resident was admitted with a diagnosis of aftercare for an orthopedic encounter and had a fragile right knee capable of dislocation, supported with an immobilizer. The quarterly MDS showed the resident was cognitively intact with a BIMS score of 13 and required ADL support. Physician orders dated 2/18/2026 prescribed a right knee immobilizer to restrict movement of the right knee, but the care plan dated 3/18/2026 contained no focus, goals, or interventions related to the immobilizer, despite the facility’s policy requiring a comprehensive person-centered care plan and a baseline care plan within 48 hours of admission. Nursing documentation on admission noted the presence of the right knee immobilizer, but there were no subsequent orders or care plan interventions detailing how staff should manage or care for the device. During interviews, the resident reported that staff sometimes provided bed baths and other times wrapped the knee in plastic and used a shower bed, but that no staff had removed the brace to check her skin, removed the brace for care, or washed the brace. The resident stated she did not believe staff knew how to care for the brace and was reluctant to allow them to remove or check it. She reported becoming concerned when the brace developed a foul smell and stated that her representative eventually brought a brace from home and replaced the dirty, smelly brace. A CNA reported having no instructions on the CNA care plan regarding how to provide ADL care for the brace and stated she relied on common sense, not removing the brace and wrapping it to keep it dry during bathing. The attending physician stated he expected the immobilizer to be removed periodically for skin breakdown prevention, with the knee kept flat and non–weight bearing during hygiene care, and noted that no one from the facility had called for order clarification. A physician assistant stated that when a resident is admitted with an orthotic device, staff should report to the physician to obtain orders for application, removal, and daily care, and that this had not occurred. The DON acknowledged that the admitting LVN documented the immobilizer, but there were no orders or care plan interventions for it, and stated she expected the ADON to have obtained care instruction orders and updated the care plan, which had not been done.
Inaccurate Documentation of Knee Immobilizer in Medical Record
Penalty
Summary
The facility failed to maintain complete, accurate, readily accessible, and systematically organized medical records for a resident with a right knee immobilizer. The resident was admitted with a diagnosis of aftercare for an orthopedic encounter and had a physician’s order dated 2/18/2026 for a right knee immobilizer to restrict movement of the right knee. The quarterly MDS documented that the resident was an older female admitted for long-term care with ADL support needs, a fragile right knee capable of dislocation, and supported with an immobilizer, and the resident had a BIMS score of 13/15 indicating no cognitive impairment. Nursing progress notes by an LVN on 2/2/2026 documented that the resident had a right knee immobilizer and that there were no concerns at that time. Despite this, weekly skin assessments completed by LVN G on 2/12/2026, 2/19/2026, and 2/26/2026 documented that the resident did not have a brace, even though the resident was wearing a right knee brace. During interviews, the resident reported having a bad right knee that had given out, leading to a fall at home, subsequent hospitalization, and an orthopedic procedure after which an immobilizer was provided to prevent dislocation. CNA B confirmed that the resident had a right knee immobilizer, and LVN G acknowledged recognizing the brace during initial assessment and stated he was unaware he had documented “no brace” on some weekly skin assessments, describing this as an oversight that could result in an inaccurate record. The DON stated the expectation that all staff documentation be accurate, and the facility’s medical records policy stated that every resident must have an accurate record.
Failure to Report Alleged Drug-Related Incident to State Agency Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged violation involving possible neglect and exploitation to the State Survey Agency within 24 hours, as required by regulation and the facility’s own abuse prevention policy. An incident occurred in which a package containing multiple baggies of a crystal-like substance suspected to be narcotics was delivered under suspicious circumstances and came into the possession of a resident. Although the facility notified law enforcement and secured the substance, the Administrator did not report the allegation to the State Survey Agency (HHSC). The Administrator stated he relied on a provider letter for guidance and believed there was no requirement to report because there was no concern for the residents’ health or safety and no evidence that the residents had contact with or used the drugs. Resident #1 was an adult male with legal blindness, type 2 diabetes mellitus, and schizophrenia. His care plan documented impaired visual function/blindness with interventions including assistance with ADLs as needed. His quarterly MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and he required moderate assistance with toileting and bathing, was non‑ambulatory, but able to stand unassisted. Resident #2 was an adult female with a right tibia fracture with routine healing, major depressive disorder, and edema. Her care plan identified a self‑care performance deficit with monitoring for changes in care or declines in function. Her quarterly MDS showed a BIMS score of 15, indicating she was cognitively intact, with independence in most functions except for moderate lower‑body involvement and non‑ambulatory status. According to the facility’s investigative report and a local police incident report, a visitor came to the facility and represented himself as a family member of Resident #2 in order to drop off a package. LVN A reported that Resident #1 asked for assistance in picking up a delivered package, and RN A assisted him in retrieving it. Upon opening the package at Resident #1’s request to check for a cross, RN A observed a cross and, underneath it, several small baggies of a white or crystal‑like substance suspected to be narcotics. Law enforcement was notified and confiscated approximately 4 grams of the substance. Interviews with both residents indicated they believed they were receiving a decorative cross from a man associated with a former resident, and both denied any knowledge of or involvement with drugs. RN A, the weekend supervisor, reported that he assisted Resident #1 with the front door when a man delivered a gift purportedly for Resident #2. The man handed the package to Resident #1, who gave the man a bag of chips in return. RN A stated that when he inspected the package for the cross, he found the suspected drugs, questioned Resident #1, and then secured the substance, notified the DON and Administrator, and contacted the police. The DON confirmed she was called in the middle of the night about a package containing a cross or rosary and a small baggie, and she instructed RN A to notify the police. She stated that packages from unknown sources were to be opened in the presence of the resident and that the staff responded as expected. The Administrator stated he was notified by RN A, confirmed that the suspected drugs were secured and turned over to police, and conducted an internal investigation, concluding there had been a mix‑up with the package and no evidence of drug use by either resident. Despite the facility’s abuse prevention policy stating that alleged violations would be reported via phone or email to the State Licensing Agency, the Administrator acknowledged that he did not report this incident to HHSC. He explained that he relied on a provider letter for reporting guidance and did not see anything indicating that this type of incident needed to be reported, particularly because he believed there was no impact on the residents’ health or safety and no contact with the drugs. The survey findings concluded that the facility failed to ensure that all alleged violations involving abuse, neglect, or exploitation that did not involve abuse resulting in serious bodily injury were reported to the State Survey Agency within 24 hours, as required, for two residents reviewed for freedom from abuse, neglect, and exploitation.
Failure to Provide Post-Fall Care and Monitoring for Resident on Anticoagulants
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, hypertension, and on blood thinners (aspirin and clopidogrel) experienced a fall in the facility. The resident was found on the bathroom floor after attempting to transfer herself from her wheelchair to the toilet. The nurse assessed the resident for injuries and reported none were found, but the resident stated she hit the back of her head. The nurse notified the physician's office, which instructed to follow protocol, and neuro checks were initiated. However, there was confusion and lack of clarity regarding the facility's protocol for residents on anticoagulants who sustain a head injury, with some staff believing the resident should have been sent to the hospital, while others stated monitoring was sufficient. Documentation and communication failures were evident throughout the incident. The time of the fall was not clearly documented, and there were missing or incomplete entries regarding interventions and physician feedback. Neuro checks were not completed as ordered, with the last documented check at 2:45 a.m. and the next scheduled check at 6:45 a.m. missing. The resident was last seen at approximately 4:30 a.m. and was found unresponsive at around 7:20 a.m. There was also a lack of proper handoff between shifts, with CNAs and nurses not consistently giving or receiving reports, and some staff unaware of the fall or the resident's condition changes. Interviews with staff revealed inconsistencies in understanding and following protocols for post-fall care, especially for residents on blood thinners. Some staff were unaware of the resident's anticoagulant status, and there was no clear written policy on whether such residents should be sent to the hospital after a head injury. The facility's documentation, monitoring, and communication lapses contributed to the resident not receiving care and services in accordance with professional standards and the comprehensive care plan, ultimately resulting in the resident's death.
Incomplete Documentation of Fall and Behavioral Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by accepted professional standards. Specifically, documentation was missing or incomplete regarding a fall, subsequent assessments, and behavioral incidents. The resident, an elderly female with a history of stroke, gout, and hypertension, experienced a fall that was not fully documented in terms of time, location, pain assessment, skin/injury assessment, or physician orders for monitoring and neuro checks. The SBAR Communication Form completed by an LVN lacked critical details, and the associated pain and skin assessments were either incomplete or absent in the electronic medical record. Additionally, there was no documentation of a behavioral incident involving verbal aggression toward a roommate and a subsequent room change. The LVN involved in the evening shift acknowledged not documenting the verbal aggression or the room change, stating she did not consider it necessary at the time. The Director of Nursing confirmed that such events, including changes in condition and behaviors requiring intervention, should be documented in the medical record to ensure appropriate monitoring and interventions. Review of facility policy indicated that all healthcare professionals are responsible for prompt and appropriate entries in the medical record, including licensed nurses' notes and other assessments. The lack of documentation for the fall, associated assessments, physician feedback, and behavioral incidents resulted in incomplete clinical records for the resident.
Verbal Abuse of Resident by LVN
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) verbally abused a resident by telling her to "shut up" during an interaction in the facility. The incident was witnessed by another staff member, who assisted the resident in reporting the event to the CNA supervisor. The resident, a female with diagnoses including encephalopathy, type 2 diabetes mellitus, schizoaffective disorder, and depression, was cognitively intact according to her BIMS score and required partial to moderate assistance with transfers. The resident was visibly upset and crying when reporting the incident to the CNA supervisor. The facility's records confirmed that the LVN made the inappropriate statement to the resident, and the event was reported promptly by staff. The facility's policy states that residents have the right to be free from abuse, neglect, and exploitation, and that employees suspected of abuse should be removed from resident care and suspended during investigation. The incident was documented in the Provider Investigation Report, and interviews with staff and other residents confirmed the occurrence of the verbal abuse and the subsequent reporting process.
Failure to Document Mechanical Lift Transfers in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents who required mechanical lift transfers. For the first resident, who had diagnoses including chronic obstructive pulmonary disease with acute exacerbation and morbid obesity, the care plan did not specify the need for transfer via mechanical lift, despite the resident being dependent on staff for transfers. Observation confirmed that staff transferred this resident using a mechanical lift, but this intervention was not documented in the care plan. Similarly, the second resident, diagnosed with vascular parkinsonism and vascular dementia and dependent on staff for all activities of daily living, had a care plan that only mentioned the use of mobility bars for repositioning in bed and encouragement to participate in care, without identifying the need for mechanical lift transfers. Observation also confirmed that this resident was transferred using a mechanical lift. Interviews with the MDS Coordinator and the DON confirmed that both residents required two-person assistance with transfers via mechanical lift, and acknowledged that the care plans did not reflect this requirement. The facility's policy requires the interdisciplinary team to develop care plans with measurable objectives and timeframes based on comprehensive assessments, but this was not followed for these residents. The lack of documentation in the care plans could result in staff not providing the required services during transfers, as the necessary interventions were not clearly identified.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Document Wound Care on Treatment Administration Record
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards for one resident. Specifically, wound care dressing changes for a male resident with a stage 3 pressure ulcer to the coccyx-buttock area were not documented on the Treatment Administration Record (TAR) for three consecutive days. The resident's care plan required daily wound care as ordered by the physician, and the facility's policy stated that treatment administration should be noted in the resident chart. However, review of the TAR showed missing nurse initials for the specified dates, indicating a lack of documentation. Interviews revealed that the RN responsible for the resident's care on those dates did provide the wound care as ordered but failed to document it due to being very busy. The RN acknowledged the omission and recognized it as a mistake. The Director of Nursing confirmed that documentation should have occurred after providing care, as it is a basic nursing responsibility and essential for communication. The lack of documentation was directly attributed to the RN's failure to record the wound care after administration.
Improper Storage of Medications and Unsecured Medication Cart
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals, as evidenced by the presence of medications at the bedside of two residents and an unsecured medication cart. Resident #89, a moderately cognitively impaired individual, was found with a large bottle of antacids at his bedside, which he used independently without being assessed for self-medication. This was confirmed by a CNA and an LVN, who acknowledged that the resident should not have had access to the antacids due to the risk of overuse and potential health complications. Resident #66, who was cognitively intact, had a bottle of hemp gummies and blood flow supplements at his bedside. The resident admitted to using these supplements without staff knowledge, which could lead to potential interactions with his prescribed medications for diabetes, heart failure, and other conditions. Both a CNA and an LVN confirmed that the resident should not have had these supplements at his bedside, as they were not prescribed by a physician and posed a risk of overdose or adverse interactions. Additionally, a medication cart was left unlocked and unattended by LVN M, who acknowledged the lapse in protocol. The cart contained medications, including narcotics, which could have been accessed by unauthorized individuals, posing a significant safety risk. The DON confirmed that medication carts should always be locked when unattended to prevent unauthorized access and potential medication misuse.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A bag of whipped nondairy cream was found in the fridge without a date, despite the label indicating it should be used within 14 days of refrigeration. The Dietary Supervisor (DS) admitted that the whipped cream had been moved from the freezer that day and should have been dated. Additionally, dry food items such as a case of water, a tub of peanut butter, and a bottle of BBQ sauce were observed on the floor outside the kitchen. The DS explained that these items were delivered that morning and placed on the floor due to the absence of a pallet, which was no longer used because it was considered to be in the way. Furthermore, the facility did not consistently log temperatures for all food items prior to meal service. During an observation, the DS took temperatures of several food items but failed to record them immediately and did not take temperatures for alternate items like green beans and pasta. The DS acknowledged that he should have taken and recorded temperatures for all items served. The facility's policy requires that all foods be stored at least six inches above the floor and that cold foods be maintained at temperatures of 40°F or below, while hot foods should be at 140°F or above. The failure to follow these procedures could place residents at risk for foodborne illness.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple instances of non-compliance with established protocols. In the case of Resident #22, a staff member, PTA O, did not wear a gown while providing care to the resident who was on Enhanced Barrier Precautions (EBP) due to a colostomy. Despite a sign indicating the need for EBP, PTA O only wore gloves and was unaware of the sign's significance. This oversight occurred during a transfer and hair brushing activity, which could have increased the risk of infection for the resident. For Resident #49, the facility failed to ensure proper hand hygiene and glove changes during incontinent care. CNA N did not change gloves or sanitize hands after removing a soiled brief and before handling a clean one. This lapse in protocol was acknowledged by CNA N, who admitted forgetting to change gloves, thereby risking cross-contamination and potential infection for the resident. In the case of Resident #147, ADON A did not adhere to proper infection control principles during wound care. The ADON failed to wash or sanitize hands between glove changes and improperly turned off the faucet with bare hands after washing, which could reintroduce contaminants. These actions were contrary to the facility's infection prevention policy and were recognized by the ADON as potential causes for spreading infection, which could lead to serious health consequences for the resident.
Failure to Obtain Consent for Wander Guards
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity by not obtaining consent for the use of physical restraints, specifically wander guards, for two residents. Resident #46, a female with dementia and cognitive impairments, was identified as an elopement risk and had a wander guard placed on her left lower leg without obtaining consent from her or her representative. The facility's Director of Nursing (DON) confirmed that they did not obtain consent for the wander guard and did not document notifying the family about its placement. Interviews with the resident's potential legal guardian and family members revealed that they were not informed about the wander guard or involved in care plan meetings. Similarly, Resident #49, a female with cognitive impairments and a history of cerebral infarction and schizophrenia, was also identified as an elopement risk and had a wander guard placed on her right lower leg without consent. The facility's records did not include consent for the use of the wander guard, and attempts to contact the resident's responsible party were unsuccessful. The DON acknowledged that the facility should notify the family and document the discussion in the resident's medical record, but this was not done. The facility's policy on wandering residents stated that the need for a wander guard should be assessed and that the family or responsible party should be notified. However, the policy also stated that the wander guard is not considered a restraint and does not require consent. This lack of consent and communication placed the residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life.
Failure to Validate DNR Due to Missing Witness Signature
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate an advance directive and determine their choice regarding CPR. Specifically, the facility did not obtain the necessary two witness signatures on the Out-of-Hospital Do Not Resuscitate (OOH DNR) form for a resident with severe cognitive impairment and multiple medical conditions, including dementia, dysphagia, pneumonitis, anoxic brain damage, and chronic kidney disease. The resident's care plan indicated a DNR status, but the incomplete documentation rendered the DNR invalid, potentially leading to the resident being treated as full code against their or their legal guardian's wishes. Interviews with facility staff revealed that the social worker, responsible for assisting with DNR forms, acknowledged the oversight of not obtaining a second witness signature, which invalidated the DNR. The Director of Nursing confirmed that due to the missing signature, the resident would be considered full code until the form was completed correctly. This oversight was contrary to the facility's policy, which mandates that a resident's choice about advance directives be recognized and respected, and that such directives be properly documented and communicated to the care team.
Inaccurate MDS Assessment for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically regarding urinary continence. The resident, an elderly female with a history of urinary tract infection, obstructive and reflux uropathy, and chronic kidney disease, was admitted with an indwelling urinary catheter. However, the admission Minimum Data Set (MDS) assessment inaccurately recorded the resident as occasionally incontinent of bladder, rather than noting the presence of the catheter. This error was acknowledged by the MDS Coordinator, who admitted to incorrectly marking the assessment. Observations and interviews with staff revealed that the resident was confused and often asked to go to the bathroom, despite having an indwelling catheter. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) confirmed the resident's use of the catheter since admission. The Director of Nursing (DON) also acknowledged the error in the MDS assessment, emphasizing its importance for care planning and billing. The facility did not provide an MDS policy upon request, and the CMS RAI Manual specifies that residents with indwelling catheters should be coded as 'not rated' for continence.
Failure to Identify Mental Illness in PASRR Assessments
Penalty
Summary
The facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for two residents, both diagnosed with bipolar disorder upon admission. This oversight was evident in the Level I PASRR screenings, where the question regarding the presence of mental illness was incorrectly answered as 'No' for both residents. This error in the PASRR process could potentially prevent residents with mental illness from receiving necessary services to address their mental health needs. Resident #47 was admitted with a diagnosis of bipolar disorder and exhibited severe cognitive impairment, mood indicators such as depression, and behaviors including delusions and verbal aggression. Despite these indicators, the PASRR screening did not acknowledge the mental illness diagnosis. Similarly, Resident #90, also diagnosed with bipolar disorder, was receiving antipsychotic medication without documented behaviors, yet the PASRR screening failed to recognize the mental illness diagnosis. Interviews with facility staff revealed a reliance on PASRR assessments from previous care settings, such as hospitals, without updating them to reflect current diagnoses. The MDS Coordinator expressed a belief that bipolar disorder alone, without behaviors, was insufficient for PASRR services, leading to a lack of follow-up with local authorities. The Director of Nursing acknowledged the need for staff training to ensure accurate PASRR screenings, particularly for residents on psychiatric medications.
Failure to Prevent Resident Access to Hazardous Items
Penalty
Summary
The facility failed to maintain a safe environment for Resident #89, who was found to have a pair of scissors, a large pair of nail clippers, and a disposable razor in his room. Resident #89, a male with moderate cognitive impairment and a history of conditions such as gastro-esophageal reflux disease and dysphagia, was observed using these items for personal grooming. Despite the resident's cognitive challenges, he reported using the razor for shaving and the nail clippers for trimming his nails, indicating a lack of adequate supervision and monitoring by the facility staff. During observations and interviews, both a CNA and an LVN acknowledged that Resident #89 should not have had access to these items due to the risk of self-harm. The Director of Nursing confirmed that residents with dementia or forgetfulness should not possess such items and emphasized the need for supervision. However, the facility's policy and procedure for managing accident hazards were not provided upon request, highlighting a gap in the facility's safety protocols.
Inadequate Incontinent and Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for residents who were incontinent of bowel and bladder, leading to potential risks of infection and skin breakdown. In the case of Resident #49, the facility did not ensure proper cleaning during peri and catheter care. During an observation, CNA I and CNA N did not adequately clean the resident's vaginal area, catheter tube, and buttock area. CNA N used a crumpled wipe to clean the resident's urethral opening and catheter tube, and did not clean the left side of the labia. Additionally, CNA N failed to change gloves or perform hand hygiene before handling a clean brief, which could lead to cross-contamination. Resident #91's care was also found to be deficient. The resident's indwelling urinary catheter bag was observed resting on the floor, which is a breach of infection control practices. CNA F and CNA G acknowledged the oversight and recognized the potential risk of infection and injury due to the catheter bag being on the floor. LVN H confirmed that it was the responsibility of the CNAs to ensure the catheter bag was not on the floor and that such an oversight could lead to an increased risk of infection. The facility's policies on incontinent care and catheter care were not adhered to, as evidenced by the observations and interviews conducted. The policies require proper cleaning techniques, glove changes, and ensuring catheter bags are kept off the floor to prevent infection. The deficiencies observed in the care of Residents #49 and #91 highlight lapses in following these protocols, potentially compromising the residents' health and safety.
Inadequate Maintenance of Oxygen Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required oxygen therapy, including tracheostomy care and tracheal suctioning. The deficiency was identified during observations and interviews, where it was noted that the resident's oxygen concentrator filters were covered in a thick white/gray substance. This condition was observed on multiple occasions, indicating a lack of maintenance and cleaning of the equipment, which is essential for ensuring proper oxygen delivery. The resident involved was an elderly male with acute and chronic respiratory failure, dementia, and chronic obstructive pulmonary disease. His care plan required regular oxygen treatments, and the facility's policy mandated that oxygen concentrator filters be cleaned weekly or according to the manufacturer's recommendations. However, the staff responsible for maintaining the equipment, including the RN, Maintenance Director, and HR Manager, failed to ensure the filters were clean. The RN was unaware of the presence of filters, and the Maintenance Director and HR Manager did not perform their assigned duties effectively. Interviews with the Director of Nursing (DON) revealed that the facility had assigned upper management staff as ambassadors to check the oxygen concentrators, but this system was ineffective. The DON acknowledged that dirty filters could alter the concentrator's function and potentially affect the resident's oxygen saturation. Despite the facility's policy and the DON's expectations, the deficiency persisted due to a lack of clear responsibility and oversight in maintaining the oxygen equipment.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis clinic for a resident requiring dialysis services. The resident, a male with end-stage renal disease, cognitive communication deficit, and dementia, was admitted to the facility and required dialysis treatments three times a week. The facility's policy required a Renal Dialysis Communication Form to be completed and filed on dialysis days, but this was not consistently done. The Renal Dialysis Communication Forms for the resident in March 2025 were either not provided or incomplete, with missing information from both the dialysis center and the facility staff. Interviews with facility staff, including the RN, Medical Records Clerk, ADON, and DON, revealed that there were ongoing issues with the dialysis clinic not filling out the forms and the facility not consistently following up to obtain the missing information. The staff acknowledged the importance of these forms for monitoring the resident's condition and ensuring proper care. The facility's policy emphasized the need for ongoing communication and collaboration with the dialysis facility, but this was not effectively implemented. The lack of completed communication forms meant that the facility could not adequately track the resident's condition during dialysis or respond to any changes or recommendations from the dialysis clinic. This deficiency in communication and documentation could potentially impact the resident's care and treatment.
Failure to Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse involving two residents to the state survey agency in a timely manner. In the first incident, a family member of a resident reported that the resident claimed a man had hurt her. The administrator was informed of this allegation but did not conduct a thorough investigation or report the incident to the state agency. The administrator concluded that the incident involved an x-ray technician without interviewing the technician or conducting a skin assessment on the resident. In the second incident, a resident allegedly hit another resident with a stick after the latter wandered into his room. Although staff were aware of the altercation and the allegation of abuse, the incident was not reported to the state agency. The administrator was informed of the situation but did not take appropriate steps to investigate or report the incident. The resident who was allegedly hit did not have any visible injuries, and the staff did not conduct a comprehensive investigation. The facility's failure to report these allegations of abuse could place residents at risk of unreported abuse. The administrator, who is also the Abuse Prevention Coordinator, did not follow the facility's policy for reporting and investigating abuse allegations. This lack of action and communication with the state agency highlights a deficiency in the facility's handling of abuse allegations.
Inadequate Investigation of Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with severe cognitive impairment and multiple diagnoses, including dementia and legal blindness. The resident reported to family members that a man had hurt her, but the facility's investigation was inadequate. The administrator, who is the Abuse Prevention Coordinator, did not conduct a comprehensive investigation as required by the facility's policy. This included failing to conduct interviews with other residents or staff, not completing a skin assessment, and not reaching out to the x-ray technician who was suspected to be involved. The administrator concluded that the alleged incident must have involved a male x-ray technician, as no male staff provided direct care to the resident. However, this conclusion was reached without interviewing the x-ray technician or other potential witnesses. The administrator also did not conduct any abuse and neglect training or education following the allegation. The facility's policy requires a thorough investigation, including interviews with all relevant parties and a review of the resident's medical record, which was not fully adhered to in this case. The report highlights that the facility's failure to conduct a thorough investigation could place residents at risk of abuse, causing mental, physical, or emotional harm. The administrator's actions did not align with the facility's policy on abuse prevention, which mandates a comprehensive investigation process to ensure resident safety and compliance with regulatory standards.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care documentation. For the first resident, the facility did not code a physical behavior incident on the resident's Quarterly MDS assessment. The incident involved the resident striking a family member, which was documented in the resident's care plan and progress notes but not reflected in the MDS assessment. The MDS Nurse, who was working PRN at the time, did not attend the interdisciplinary team meetings and was not informed of the incident, resulting in the incorrect coding. The second resident's Discharge MDS was inaccurately coded as discharged to Home/Community instead of to a hospital. The resident was transferred to a local hospital due to abnormal vital signs, as documented in the Nursing Home to Hospital Transfer Form and Nursing Progress Notes. The MDS Nurse responsible for the discharge coding did not recall completing the Discharge MDS and acknowledged that it should have been coded as a hospital discharge. The facility's policy requires comprehensive assessments based on the Resident Assessment Instrument, but the coding errors indicate a lapse in following this policy. Interviews with facility staff, including the MDS Nurses, DON, and OM, revealed that the miscoding did not impact the residents' care directly, as the nursing staff relied on progress notes and reports. However, the incorrect documentation could affect scheduling and billing processes. The facility's policy emphasizes the importance of accurate assessments, but the incidents highlight a communication gap and procedural oversight in ensuring that all relevant information is captured in the MDS assessments.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift, and the resident census for six consecutive days. This deficiency was observed from 07/31/2024 to 08/05/2024, with the last posted document dated 07/30/2024. The Assistant Director of Nursing (ADON) confirmed the outdated posting and acknowledged that the staffing coordinator (SC) was responsible for this task but was on vacation during the period in question. The ADON was supposed to cover this responsibility in the SC's absence. Interviews with the SC, Director of Nursing (DON), and Office Manager (OM) revealed a lack of clarity and communication regarding the responsibility for posting the daily staffing information. The SC, who was on vacation, stated that the ADONs were supposed to handle the postings in her absence. The DON and OM both confirmed this arrangement but admitted uncertainty about why the postings were not updated. Despite the oversight, the SC, DON, and OM expressed that they did not believe the absence of the postings significantly impacted resident care or staffing ratios, as they did not observe residents or facility guests referring to the document.
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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