Paradigm At First Colony
Inspection history, citations, penalties and survey trends for this long-term care facility in Missouri City, Texas.
- Location
- 4710 Lexington Blvd, Missouri City, Texas 77459
- CMS Provider Number
- 455812
- Inspections on file
- 56
- Latest survey
- March 18, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Paradigm At First Colony during CMS and state inspections, most recent first.
A resident with dementia, colostomy, and a feeding tube, who was dependent on staff for toileting and ADLs, was found by a family member on two separate occasions lying in a soiled bed with feces, urine, and tube-feeding formula after colostomy and g-tube leaks. Photos documented the resident lying in brown liquid on his abdomen, brief, clothing, and sheets, and on another occasion with an open brief and sheets soaked with a light tan substance. The family member reported these conditions to the Unit Manager, RN, and an LVN, who acknowledged the incidents and that the resident’s colostomy and feeding tube frequently leaked. Staff, including the DON and Administrator, stated residents were to be checked every two hours or as needed, and that this resident required more frequent checks due to constant leakage, but the resident was nonetheless left in these soiled conditions, contrary to his care plan and facility ADL policy.
A facility failed to recognize a resident's designated POA, refusing to provide clinical records and disregarding a notarized legal document. Despite the resident's moderate cognitive impairment, assessments showed she was alert and oriented, and both the resident and APS confirmed the POA's legitimacy. The Administrator and Social Worker denied the POA's rights based on concerns about the resident's cognition and a previously closed APS case.
Two residents with significant medical and cognitive needs did not have their call lights within reach, as required by their care plans and facility policy. One resident had to wave at staff to get attention, while another resorted to yelling for help due to inaccessible call lights. Staff interviews confirmed the expectation that call lights should always be within reach, but this was not consistently maintained.
The facility did not submit or retain required five-day investigation findings for multiple allegations of abuse, neglect, and exploitation involving several residents, including reports of rough care, failure to provide essential care, resident-to-resident altercations, and concerns of possible sexual assault and unsanitary conditions. In each case, the necessary documentation and reporting to the State Survey Agency were not completed as required.
A resident with glaucoma did not receive eye drops according to prescribed procedures, as a medication aide failed to pull down the lower eyelid and placed the medication cap on an unclean surface before replacing it. The resident did not consistently receive the correct number of drops, and the aide's actions did not align with facility policy or documented competency requirements.
A resident on anticoagulant therapy experienced an unwitnessed fall with a head injury, and the facility failed to follow its protocol by not calling 911 for immediate transport. The resident, who had a history of muscle weakness and vascular dementia, was found with swelling on her cheek and slurred speech, but was sent to the hospital via regular EMS instead of 911, contrary to facility policy. This led to an Immediate Jeopardy situation as the resident was later diagnosed with an acute subdural hematoma.
A resident on anticoagulant medication with a history of falls and severe cognitive impairment experienced multiple unwitnessed falls, resulting in a severe head injury and hospitalization. Despite being care planned for fall risks, the facility's interventions were insufficient, and the resident's mobility and dementia further complicated supervision efforts. The facility's inability to provide effective fall prevention measures led to an Immediate Jeopardy situation.
The facility failed to protect resident privacy when a CMA left a laptop open and unattended, displaying resident information, while administering medication. This allowed unauthorized individuals, including a housekeeping staff member, to view sensitive information. Interviews confirmed staff awareness of HIPAA regulations, but the incident occurred due to a lapse in following privacy protocols.
The facility did not post daily nursing staffing information from November 14 to November 19, 2024. The Staffing Coordinator, responsible for updating this information, forgot to do so, resulting in outdated information being displayed. The Administrator confirmed the lack of a staffing posting policy.
A resident's PICC line was not managed according to professional standards, lacking physician orders and care plans for monitoring and dressing changes. The line was not removed after antibiotic therapy completion, and dressings were not changed as required, posing infection risks. Staff interviews revealed communication lapses and failure to follow protocols.
The facility's kitchen faced several deficiencies, including unlabeled food items, improper storage, and infrastructure issues like improper air gaps and drain water backup. These issues were not reported to the local Department of Health, leading to a temporary closure of the kitchen by a Health Department Inspector until necessary repairs and sanitation were completed.
The facility failed to develop comprehensive care plans for two residents, one with COPD who removed her oxygen cannula, and another with incontinence issues lacking a skin care plan. These omissions could lead to unmet medical and psychosocial needs, potentially causing health declines.
A facility experienced a 15% medication error rate due to improper administration by two staff members. Errors included incorrect mixing of Pantoprazole, wrong iron supplement administration, and failure to follow instructions for Megestrol and Latanoprost. The residents involved had complex medical conditions and required total care assistance. Staff interviews revealed a lack of training, and the facility's policy did not adequately address medication administration procedures.
A facility failed to create a baseline care plan within 48 hours for a newly admitted resident with cerebrovascular disease and hemiplegia. The resident's care plan did not address potential skin issues related to incontinence, despite the resident being in bed frequently. Interviews with the DON and MDS Coordinators confirmed the oversight and acknowledged the potential for negative outcomes like skin breakdown.
Two residents with pressure ulcers did not receive necessary treatment and services as per physician orders. One resident was not provided with an air mattress upon readmission, despite having a stage 4 sacral wound. Another resident's wounds were not properly cleaned before dressing, as required. These deficiencies highlight lapses in following physician orders and providing appropriate care.
A resident with complex medical conditions, including paraplegia and an indwelling Foley catheter, did not receive appropriate catheter care. During a pressure ulcer treatment, the catheter was placed on the bed with urine in the bag, contrary to facility policy requiring the catheter bag to be below bladder level. The LVN involved was unsure who placed it there, despite knowing the risk of infection. Records showed no evidence of proper catheter care or monitoring.
A facility failed to ensure sterile technique during tracheotomy care for a resident with a tracheostomy. RN G did not wash hands or use hand sanitizer between glove changes and did not maintain sterile technique, potentially risking infection. The DON confirmed RN G was not in-serviced on tracheostomy care, contrary to facility policy.
A facility failed to maintain proper infection control when a resident's oxygen cannula was found under bedsheets and not disinfected before being bagged by an RN. The resident, with COPD and independent in most self-care, had orders for oxygen use. Interviews revealed inconsistent infection control practices, and no specific oxygen policy was provided, despite the facility's program emphasizing evidence-based policies to reduce infection risks.
A facility failed to uphold residents' rights to dignity and respect when two staff members laughed and made derogatory comments during an incident involving a resident with cognitive impairment entering another resident's room. The affected residents felt unsafe and disrespected, with one resident expressing a desire to leave the facility. Staff interviews revealed a lack of acknowledgment of the inappropriate behavior, highlighting a deficiency in maintaining a respectful environment.
A facility failed to report an alleged abuse incident involving a resident with severe cognitive impairment. The resident's family reported that the resident was slapped by an unknown CNA, but the allegations were not communicated to the Director of Nursing or the abuse coordinator, nor reported to the State Health Department within the required timeframe. This lack of communication and adherence to policy potentially placed residents at risk.
A resident with severe cognitive impairment reported being slapped by a CNA, but the LTC facility failed to report the allegations to the State Survey Agency as required. Despite the resident's inconsistent recollection and lack of physical evidence, the facility's policy mandates reporting such incidents. Interviews revealed a breakdown in communication and reporting procedures, with key staff unaware of the allegations.
The facility failed to ensure the dumpster door was closed when not in use, as observed during a survey. The dumpster, located behind the dietary department, was found three-quarters full with its door open. The Dietary Food Service Manager confirmed that the door should be closed to prevent pests and insects from accessing the dumpster. The responsibility for closing the dumpster doors was shared among dietary, nursing, and housekeeping staff. The facility's waste disposal policy requires dumpsters to be closed at all times.
A facility failed to document a resident's pain level accurately, leading to incomplete clinical records. The resident, with multiple health conditions including an amputation, had inconsistent pain assessments, and a significant pain level was not documented when pain medication was ordered. Interviews revealed that the LVN forgot to document the pain complaint and the call to the doctor, which could affect the resident's care.
The facility failed to maintain accurate clinical records and document a resident-to-resident altercation. A resident was misidentified on his Facesheet and psychiatric assessment, and an altercation was not recorded in the incident report. This lack of documentation could lead to inappropriate care and inadequate monitoring of residents' behaviors.
A resident with multiple health issues, including legal blindness, was unable to use her call light due to a missing button, leaving her unable to call for assistance. Despite being aware of the issue, nursing staff did not check the call light's functionality, and the maintenance director was not informed. The facility's policy required functional call lights, but there was confusion among staff about responsibility for ensuring this, resulting in the resident not receiving timely care.
Failure to Maintain Resident Dignity and Provide Timely Incontinence and Device Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and adequate assistance with activities of daily living and incontinence care, resulting in a resident being left in soiled conditions on two separate occasions. The resident was an elderly male with dementia, dysphagia, esophageal obstruction, colostomy status, ileus, and intestinal obstruction, who was dependent on staff for toileting and incontinent care and had both an indwelling catheter and an ostomy. His care plan and orders required staff to monitor and manage his colostomy and feeding tube, provide extensive assistance with ADLs, and assist with incontinent care and repositioning. On one evening, a family member reported that after visiting the resident, cleaning him, changing his bed sheets, and cleaning his floor, she left and returned about an hour later to find him covered in feces. A photo from that date showed the resident lying in a light brown liquid substance on his colostomy bag, stomach, adult brief, bedsheets, and clothing. The family member brought the Unit Manager and an RN to the room and requested that the resident be showered. The Unit Manager and RN later confirmed that they recalled the incident, described the colostomy bag as leaking, and stated that they did not know how long the resident had been in that condition. On another occasion, the same family member reported that when she visited and removed the sheet from the resident, his adult brief was open underneath him and the bed was soaked with urine and tube-feeding formula. A photo from that date showed an open adult brief with light tan stains and bed sheets soaked with a light tan substance. The family member called an LVN to the room and showed him the condition. Staff interviews, including with the Unit Manager, RN, DON, Administrator, and LVN, acknowledged that the resident’s colostomy and feeding tube frequently leaked, that residents were supposed to be checked every two hours or more frequently as needed, and that the resident would need to be checked more often due to frequent leakage. The facility’s ADL policy stated that necessary assistance and supervision would be provided when residents were unable to perform ADLs independently.
Failure to Honor Resident's Power of Attorney and Rights
Penalty
Summary
The facility failed to honor a resident's right to have her designated Power of Attorney (POA) exercise her rights, as required by state law. The POA, who was a friend and neighbor of the resident, provided a notarized Texas Durable Power of Attorney document to the facility. Despite the document being properly signed and notarized, the facility Administrator determined it was invalid, citing the resident's cognitive impairment and questioning the legitimacy of the notary. The Administrator instructed staff not to provide the requested clinical records to the POA and referred to the POA documentation as a 'trash piece of paper.' The resident in question was an elderly female with a history of altered mental status, muscle weakness, anxiety, and mood disturbance. Upon admission, her cognitive status was assessed as moderately impaired, but subsequent evaluations indicated she was alert, oriented, and had adequate judgment. The resident confirmed she knew her POA, trusted her, and was not coerced into signing the POA document. She also expressed willingness to move to another facility to be closer to her POA. Staff interviews revealed that the facility's decision to deny the POA's rights was influenced by a previously open Adult Protective Services (APS) case, although APS confirmed the case was closed with no allegations against the POA. The Social Worker and Administrator both cited concerns about the POA's validity due to the APS involvement and the resident's cognitive status, despite documentation and statements from both APS and the resident supporting the POA's legitimacy. The facility's actions resulted in the POA being denied access to the resident's clinical records and the ability to assist in her care decisions.
Failure to Ensure Call Lights Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans and facility policy. For one resident, who had diagnoses including non-Alzheimer's dementia, stroke, spinal stenosis, and muscle weakness, the call light was observed hanging behind the right side of the bed, out of reach, while the bed controls were accessible. The resident reported that staff sometimes did not return the call light to her reach after providing assistance, and she would wave at staff passing by to get help if she could not reach the call light. Her care plan specifically required that the call light and bed controls be within reach at all times to mitigate her risk for falls and injuries. Another resident, with severe cognitive impairment and multiple medical conditions such as heart failure, neurogenic bladder, and respiratory failure, was found with his call light behind the bed and nightstand, tangled among other cords and not accessible. He stated he often had to yell for help because the call light was not on his bed. Staff interviews confirmed that it was the nurses' responsibility to ensure call lights were within reach and that all staff were expected to check call light placement. The facility's policy required call lights to be accessible and within reach of the resident's bed or sitting area, but this was not followed for these two residents.
Failure to Submit and Retain Required Abuse and Neglect Investigation Reports
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, and exploitation were thoroughly investigated and that the results of these investigations were reported to the State Survey Agency within five working days, as required. This deficiency was identified for six out of eight residents reviewed for abuse, neglect, and exploitation. Specific incidents included allegations of rough care during activities of daily living (ADL) assistance, rough care during medication pass, failure to provide essential care, resident-to-resident physical altercation, and concerns of possible sexual assault and unsanitary conditions. In each case, the facility did not submit the required five-day investigation findings via the TULIP database, and no additional information related to the incidents was found in the system. For example, two residents with self-care deficits and intact cognition reported that a CNA was rough during ADL care, but the facility did not identify the CNA in documentation, nor did it submit a five-day investigation report. Another resident's family member alleged rough care during medication administration, but again, no five-day investigation findings were submitted, and documentation was lacking regarding the incident details and staff training at the time. In a separate case, a resident's responsible party alleged that a CNA failed to provide essential care, but the facility did not submit the required investigation findings, and the CNA could not recall the details of the incident. Additional incidents included a resident hitting another resident, with both residents having behavioral health diagnoses and care plans addressing aggression and psychotropic medication management. Despite assessments and interventions being documented in the clinical record, the facility did not submit the required five-day investigation findings. Another case involved an allegation of possible sexual assault, lack of catheter dressing, and unsanitary room conditions, reported by an insurance provider, but again, no five-day investigation findings were submitted. Staff interviews confirmed awareness of abuse and neglect training, but the required documentation and reporting of thorough investigations were not completed or retained as required by facility policy and regulation.
Improper Eye Drop Administration and Medication Handling
Penalty
Summary
The facility failed to provide proper pharmaceutical services in the administration of eye drops to a resident with glaucoma and other significant medical conditions. During a medication pass, a medication aide did not pull down the lower eyelid before instilling the prescribed Latanoprost eye drops, contrary to facility policy and standard procedure. Additionally, the aide placed the medication cap with the inside facing down on an unclean nightstand surface, which was not disinfected prior to the procedure, and then replaced the cap onto the bottle after administration. The resident involved was an elderly female with a history of heart failure, fainting, glaucoma, and elevated blood pressure. She had severe cognitive impairment and required varying levels of staff assistance for activities of daily living. The resident's care plan noted impaired visual functioning and risk for decreased ADLs due to glaucoma, but did not specify interventions for medication administration as ordered by the physician. Observation revealed that the medication aide instilled the eye drops without forming a pouch by pulling down the lower eyelid, and the resident did not always receive the correct number of drops as ordered. The aide also failed to maintain the cleanliness of the medication cap, potentially contaminating the dropper. These actions were inconsistent with both the facility's policy and the aide's documented competency checklist, which required proper technique for eye drop administration.
Failure to Follow Protocols for Resident on Anticoagulants After Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices. The deficiency involved a resident who was on anticoagulant therapy with Eliquis and experienced an unwitnessed fall with a head injury. Despite the resident's condition, the facility delayed sending the resident to a higher level of care, opting for regular EMS transport instead of 911, which was against the facility's policy for such incidents. The resident, who had a history of muscle weakness, unsteadiness on feet, vascular dementia, end-stage renal disease, and osteoporosis, was found sitting on the floor with swelling to the right cheek. The resident's vital signs were stable, and she denied any pain, but her speech was slurred, which was not immediately acted upon as a potential sign of a serious condition. The nurse on duty, RN A, used her judgment to send the resident to the hospital via regular EMS, despite knowing the resident was on blood thinners and the facility's policy required 911 transport for unwitnessed falls with head injuries. Interviews revealed that the facility did not have a specific policy for unwitnessed falls with head injuries for residents on anticoagulants, and the DON was not aware of the resident's medication regimen. The facility's failure to follow proper procedures and the lack of immediate action in response to the resident's condition led to the identification of an Immediate Jeopardy situation, as the resident was later diagnosed with an acute subdural hematoma and required emergency medical intervention.
Removal Plan
- CR #1 was transferred to hospital.
- The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting to review the IJ template and Plan of Removal.
- RN A was suspended pending investigation.
- The Director of Nursing and Assistant Director of Nursing assessed residents who had unwitnessed fall for any signs or symptoms of headache, vomiting, or abnormal findings to the scalp/head with no adverse findings.
- The Director of Nursing initiated an in-service with licensed nurses. Topics included: Fall Procedures, specifically on activating the emergency response system (911) for any residents who has a fall with a visible head injury. 911 should be activated upon identification and notification to Physician and the DON would be secondary. Licensed nurses will be educated before starting their next shift. Education will be included in orientation.
- The Director of Nursing provided 1:1 education with RN A. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury. 911 should be activated upon identification of the abnormal findings and notification to Physician and DON would be secondary; and completing through assessments post-fall with consideration for residents on anticoagulants.
- The Regional Nurse Consultant provided 1:1 education with the DON. Education included Fall Procedures and activating the emergency response system (911) for any resident who has a fall with a visible head injury ' 911 should be activated upon identification and notification to Physician and DON secondary; and completing through assessments post-fall with considerations for resident on anticoagulants.
- Fall documentation will be reviewed each weekday in morning meeting on weekends, holidays, and after hours by DON/designee to ensure completed and appropriate actions are taken and documented.
- The Administrator and DON reviewed the policy on Fall Management and Changes of Condition no changes noted.
Inadequate Supervision Leads to Resident Falls and Injury
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident who was on anticoagulant medication. This resident, who had a history of falls and was diagnosed with conditions such as muscle weakness, unsteadiness on feet, vascular dementia, end-stage renal disease, and osteoporosis, experienced multiple unwitnessed falls within a short period. Despite being care planned for fall risks, the interventions in place were insufficient to prevent these incidents, leading to a severe head injury and hospitalization. The resident's care plan included interventions such as anticipating needs, providing prompt assistance, ensuring adequate lighting, and encouraging the resident to ask for help. However, these measures were not effective, as the resident continued to fall, with incidents occurring on several dates in November. The resident's cognitive impairment, indicated by a BIMS score of 7, contributed to her inability to remember to use the call light for assistance, further complicating the situation. Interviews with facility staff revealed that the resident was often placed in the common area near the nurse station for supervision, but she was mobile in her wheelchair and could move freely, which increased the risk of falls. The facility acknowledged the challenges posed by the resident's dementia and mobility but did not have the staffing resources to provide one-on-one supervision. The repeated falls and the facility's inability to implement effective interventions led to the identification of an Immediate Jeopardy situation, highlighting the need for a more robust fall prevention strategy.
Removal Plan
- The Administrator, Director of Nursing, and Medical Director held an ADHOC QAPI meeting to review the IJ template and Plan of Removal.
- CR #1's care plan was reviewed and fall interventions updated by MDS Coordinator after each fall.
- The Regional Nurse did 1:1 in-service with MDS on fall management and developing individualized fall prevention plans.
- Residents who experience a fall event are reviewed during the daily clinical morning meeting by the Interdisciplinary Team (IDT).
- The facility will identify residents who are on anticoagulants by Physician Orders, Anticoagulant Care Plans, and side effect monitoring on the EMAR.
- Residents are assessed for risk for falls by the charge nurse on admission, quarterly, with significant change and fall events.
- The Director of Nursing initiated an in-service with licensed nurses on fall management, change of condition, and Kardex.
- The Director of Nursing provided education with staff members that provide direct care to residents.
- The Regional Nurse Consultant provided 1:1 education with the DON on fall management and developing individualized fall prevention plans.
- The Administrator and DON reviewed the policy on Fall Management with no changes required.
- Fall trends are brought to QAPI and reviewed monthly with the Medical Director.
- The Administrator reviewed the facility assessment, staffing on the memory care unit (supervision), and residents who are at risk for falls with no adverse findings identified.
Failure to Protect Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy of residents' personal and medical records for seven out of ten residents reviewed. During an observation, a laptop on the nurse's cart was left open and unattended, displaying the full names and room numbers of seven residents. This occurred while CMA A was in a resident's room administering medication, leaving the laptop accessible to unauthorized individuals, including a housekeeping staff member who was in direct sight of the screen. Interviews with CMA A and RN A confirmed that the staff was aware of the requirement to lock computer screens to protect resident information, as per HIPAA regulations. CMA A admitted to forgetting to lock the screen, acknowledging it as a violation of privacy protocols. The facility's policies on resident rights and HIPAA compliance emphasize the importance of safeguarding resident information from improper use and disclosure, which was not adhered to in this instance.
Failure to Post Daily Nursing Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nursing staffing information was posted and readily accessible for review from November 14 to November 19, 2024. During an observation on November 19, 2024, at 9:09 a.m., it was noted that the staffing information displayed at the receptionist desk was outdated, showing the date of November 13, 2024. An interview with the Staffing Coordinator revealed that she was responsible for updating the daily nursing staff information but had forgotten to do so for the past few days. The Administrator confirmed that the Staffing Coordinator was tasked with this responsibility and acknowledged that the daily staffing information should be posted at the front of the facility each day. Additionally, the Administrator mentioned that the facility did not have a staffing posting policy in place.
Failure in PICC Line Management and Monitoring
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically in the management of a peripherally inserted central catheter (PICC) line. The resident, who was readmitted from the hospital with a PICC line, did not have physician orders or a care plan in place for monitoring and dressing changes of the PICC line. This oversight persisted from the time of the resident's readmission until the PICC line was ordered to be discontinued by a nurse practitioner. The resident's PICC line was not removed after the completion of IV antibiotics, and the dressing was not changed according to the facility's policies, which require changes every 5 to 7 days. Observations revealed that the resident's PICC line had two tape dressings, one of which was dated from the hospital stay, and both dressings appeared brownish in color, indicating they had not been changed as required. Interviews with various staff members, including the Director of Nursing (DON), Licensed Vocational Nurses (LVNs), and the Nurse Practitioner (NP), highlighted a lack of communication and adherence to protocols. The NP admitted to not placing orders for the PICC line's discontinuation or dressing changes, and the nursing staff failed to notify the physician upon completion of the antibiotic therapy. The deficiency was identified as an immediate jeopardy situation, posing a risk of infection and sepsis due to the prolonged presence of the PICC line and lack of proper dressing changes. The facility's staff, including the DON and Administrator, acknowledged the failure to follow physician orders and the potential infection control concerns. The lack of documentation and communication among the nursing staff and the NP contributed to the oversight, resulting in the resident's PICC line being left in place longer than necessary without appropriate monitoring and care.
Removal Plan
- Resident #37's PICC line was assessed by the Director of Nursing with no adverse effects or signs or symptoms of infection noted.
- A physician's order was obtained for the removal of the PICC line, and PICC line was discontinued without adverse effects.
- The Physician ordered lab work and results were noted with no adverse findings.
- All other residents with central lines were assessed by the Director of Nursing to ensure an up-to-date dressing, active order sets to include monitoring, flushes, dressing changes, orders to obtain central lines after IV therapy is completed, and central line specific care plans.
- The Administrator and DON informed the Medical Director of the Immediate Jeopardy situation through an AD Hoc QAPI meeting.
- The Regional Nurse Consultant provided 1:1 education with the DON on providing oversight with residents with central lines and ensuring compliance with central line policies and procedures.
- The Director of Nursing initiated in-services with licensed nurses on ensuring compliance with central line policies and procedures.
- The Director of Nursing conducted 100% rounds on residents with central lines and compliance was noted with policies and procedures.
- The Administrator reviewed the Central Line Policies and Procedures and no changes were required.
- The charge nurse will input and complete orders for residents who obtain or admit with a central line and will be validated in clinical morning meeting by nurse leadership.
- The clinical morning meeting will include reviewing high risk residents to include residents with central lines and ensuring compliance with central line policies and procedures.
Food Safety and Infrastructure Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several deficiencies observed in the kitchen. During an inspection, it was noted that multiple food items in the walk-in refrigerator were not labeled with dates of opening or preparation, contrary to the facility's policy requiring such labeling and disposal after 72 hours. Additionally, cases of canned food were found stored directly on the floor in the storage room, which poses a risk of cross-contamination. Further observations revealed significant issues with the kitchen's infrastructure, including a wet floor near the dish machine and three-sink compartment, and improper air gaps in the ice machine and dish machine, which are necessary to prevent backflow. There were also holes in the ceiling and walls near the Dietary Food Service Manager's office, which could allow pest entry. A drain water backup was observed on the kitchen floor, and it was discovered that the facility had not self-reported this issue to the local Department of Health, as required by city ordinance. Interviews with the Dietary Food Service Manager and other staff revealed a lack of immediate action and reporting regarding the drain water backup and air gap issues. The facility continued operations despite the presence of these hazards, and it was only after a Health Department Inspector's visit that the kitchen was ordered to cease operations. The facility's failure to maintain proper food safety standards and infrastructure, along with inadequate reporting and response to the sewage backup, led to the closure of the kitchen until necessary repairs and sanitation were completed.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #88, who has a history of chronic obstructive pulmonary disease (COPD) and other medical conditions. Despite having physician orders for oxygen therapy, the care plan did not address Resident #88's behavior of removing her oxygen cannula and not storing it properly, which poses a risk of infection and fire hazard. Observations revealed that the cannula was left on the bed, and interviews with staff indicated that there was no consistent monitoring or cleaning of the oxygen equipment, despite the resident's noncompliance with keeping the oxygen on. Resident #43, who has cerebrovascular disease and is always incontinent of bladder and frequently incontinent of bowel, also lacked a comprehensive care plan addressing potential skin issues. The resident's admission records and assessments indicated a need for skin care planning due to incontinence, but this was not included in the care plan. Interviews with the Director of Nursing and MDS Coordinators revealed that the omission was an oversight, and the potential negative outcomes of not addressing skin issues were acknowledged. The facility's failure to include these critical aspects in the care plans for Residents #88 and #43 could lead to unmet medical, functional, and psychosocial needs, potentially causing a decline in their health. The facility's care planning policies require comprehensive care plans to be developed within seven days of the comprehensive assessment, but this was not adhered to in these cases.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to provide proper pharmaceutical services, resulting in a medication error rate of 15%, which is significantly higher than the acceptable threshold of 5%. This deficiency was observed in the administration of medications to two residents by two staff members, MA A and RN A. Specifically, MA A did not follow physician orders when administering Pantoprazole granules mixed with yogurt instead of apple juice or applesauce, and incorrectly gave Ferrous Gluconate instead of Ferrous Sulfate to a resident. Similarly, RN A failed to administer medications correctly by not shaking Megestrol oral suspension as required, administering the wrong iron supplement, and giving Latanoprost eye drops at the wrong time of day. The residents involved had complex medical histories, including conditions such as sepsis, schizophrenia, hypertension, heart failure, and respiratory distress. One resident required total care assistance with activities of daily living and had moderately impaired cognition, as indicated by their BIMS score. The errors in medication administration could potentially impact the therapeutic outcomes and health of these residents, as the medications were not given as prescribed by their physicians. Interviews with the staff involved revealed a lack of proper training and oversight in medication administration. MA A admitted to not having received medication training since starting at the facility and acknowledged the errors made. RN A also expressed regret for the mistakes and noted the absence of in-service training on medication administration. The Director of Nursing, who had recently started at the facility, confirmed that the staff had been trained according to the facility's policy, but additional training would be provided. However, the facility's policy did not adequately address the timely and correct administration of medications.
Failure to Develop Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop a person-centered baseline admission care plan for a resident within 48 hours of admission. The resident, a cognitively intact male with cerebrovascular disease and hemiplegia following a stroke, was admitted to the facility. The resident's admission records indicated impairments in upper and lower extremities and incontinence issues. However, the baseline care plan did not address the resident's potential for skin issues related to incontinence, which was a significant oversight given the resident's condition. Interviews with the Director of Nursing (DON) and MDS Coordinators revealed that the resident should have had a care plan addressing skin issues due to his incontinence and time spent in bed. The MDS Coordinators acknowledged the oversight and the potential negative outcomes, such as skin irritation and breakdown, that could result from not having a care plan in place. The facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the resident, leading to the deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for residents with pressure ulcers, as observed in two cases. One resident, a male with a history of pressure ulcers and other medical conditions, was not provided with an air mattress as ordered by the physician upon readmission. Despite having a stage 4 sacral wound and being at risk for further skin breakdown, the resident was left on a regular mattress until the order was placed for an air mattress. This oversight persisted despite multiple progress notes indicating the need for a Group-2 mattress to aid in wound healing and pressure reduction. In another case, a resident with multiple stage 4 pressure ulcers did not receive proper wound care as per physician orders. The wound care nurse failed to clean the wounds with normal saline and pat them dry before applying dressings, as was required. This lapse occurred during a wound care session observed by a wound care doctor, who measured the ulcers but did not ensure the wounds were cleaned before dressing. The nurse misunderstood the doctor's instructions, leading to incomplete wound care, which could potentially hinder healing and increase the risk of infection. Both cases highlight significant lapses in following physician orders and providing appropriate care for residents with pressure ulcers. The facility's failure to ensure the use of prescribed equipment and adherence to wound care protocols directly contributed to the deficiencies observed. These actions and inactions could place residents at risk for worsening of existing wounds or the development of new pressure ulcers.
Improper Foley Catheter Management Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling Foley catheter, which is crucial for preventing urinary tract infections and maintaining continence. The resident, a male with multiple complex medical conditions including paraplegia, stage 4 pressure ulcers, and an indwelling catheter, was observed during a pressure ulcer treatment session. During this session, the Foley catheter was improperly placed on the bed with approximately 350 cc of urine in the bag, contrary to the facility's policy that requires the catheter bag to be positioned below the bladder level to ensure proper drainage and prevent urine reflux. The resident's medical records indicated a lack of documented evidence for Foley catheter care, monitoring, and output from the specified period. An interview with the LVN involved revealed uncertainty about who placed the catheter on the bed, despite acknowledging that such placement could lead to urinary tract infections. The facility's policy on catheter care, revised in February 2024, clearly outlines the need for proper catheter management, which was not adhered to in this instance.
Failure to Use Sterile Technique in Tracheotomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring tracheotomy care and suctioning, as observed during a survey. Specifically, RN G did not use sterile technique during tracheotomy care and suctioning for a resident with a tracheostomy. The resident, a male with acute respiratory failure and other significant health issues, was observed in bed with audible moist breath sounds. RN G performed tracheotomy care without washing hands or using hand sanitizer between glove changes, and did not maintain sterile technique while handling the tracheostomy equipment. During interviews, RN G admitted to not using sterile technique and acknowledged the risk of infection posed by her actions. The Director of Nursing (DON) confirmed that RN G had not been in-serviced on tracheostomy care and had only started working at the facility three days prior. The facility's policy requires aseptic technique during tracheostomy care, which was not followed in this instance, potentially placing the resident at risk for respiratory infections.
Inadequate Infection Control for Oxygen Cannula
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the handling of a resident's oxygen cannula. The deficiency was identified when the oxygen cannula of a resident with chronic obstructive pulmonary disease (COPD) was found underneath two bedsheets and a blanket on her bed. The resident, who was cognitively intact and independent in most self-care activities, had a physician's order for oxygen to maintain her oxygen saturation levels. However, the facility did not ensure that the cannula was properly disinfected before being placed in a plastic bag by a registered nurse (RN). Interviews with the RN and the facility's Administrator revealed a lack of consistent infection control practices regarding the handling of the oxygen cannula. The RN acknowledged the risk of infection control issues, while the Administrator noted that the resident's behavior of leaving the cannula on the bed was care-planned. Despite this, the facility's Infection Control Program emphasized the importance of evidence-based policies to reduce infection risks, yet no specific oxygen policy was provided upon request. This oversight in infection control practices could potentially place residents at risk of cross-contamination and infection.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure the residents' right to respect and dignity, as evidenced by the actions of CNA M and MA J during an incident involving three residents. Resident #73, who has a history of altered mental status and moderate cognitive impairment, entered the room of Resident #78 and began pulling her hair and t-shirt. Resident #78, who has intact cognition but limited mobility due to an amputation, was frightened and screamed for help. Staff members, including CNA M and MA J, responded to the situation by laughing and referring to Resident #73 as 'crazy,' which was perceived as disrespectful and dismissive by the affected residents. Resident #78 expressed feeling unsafe and emotionally distressed by the incident, stating that the staff's reaction made her feel bad and that the facility did not take the situation seriously. She described the facility as a 'madhouse' and expressed a desire to leave for a more peaceful environment. Resident #70, who witnessed the incident from her bed, corroborated Resident #78's account, noting that the staff's laughter and comments about Resident #73 being 'crazy' were unprofessional and made her feel bad for Resident #78. Interviews with staff members revealed a lack of awareness or acknowledgment of the inappropriate behavior. CNA M and MA J denied laughing or making derogatory comments, and the facility's administration stated that they were unaware of any staff misconduct. Despite this, the residents' accounts and the facility's policy on resident rights highlight a failure to maintain a respectful and dignified environment, contributing to the deficiency noted in the report.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator, as required by their policy. This deficiency was identified in the case of a resident who was reported to have been slapped by an unknown CNA. The resident, who had severe cognitive impairment and multiple medical diagnoses including dementia and Alzheimer's disease, was unable to recall the incident clearly or provide specific details about the alleged perpetrator. Despite the report from the resident's family member to a manager on duty, the allegations were not communicated to the Director of Nursing or the designated abuse coordinator, and no report was made to the State Health Department within the required 24-hour timeframe. The incident was documented in the resident's progress notes by an LVN, who noted that the family had reported the alleged abuse. However, the LVN did not ensure that the report was escalated to the appropriate authorities within the facility. Interviews with staff, including the Director of Nursing and the Administrator, revealed a lack of communication and follow-through on the abuse allegations. The facility's policy on abuse, neglect, and exploitation, which mandates immediate reporting to the state, was not adhered to, resulting in a failure to protect the resident and potentially placing other residents at risk for abuse or neglect.
Failure to Report Alleged Abuse in a Resident with Dementia
Penalty
Summary
The facility failed to report allegations of abuse involving a resident who claimed to have been slapped by a CNA. The resident, who has severe cognitive impairment due to dementia and other medical conditions, reported the incident to a family member. The family member then informed the facility staff, but the allegations were not reported to the State Survey Agency as required by the facility's policy. The resident's medical history includes chronic obstructive pulmonary disease, dementia, schizophrenia, and Alzheimer's disease, which contribute to her cognitive challenges. The incident was first reported by the resident to her family member, who then communicated it to the facility's LVN. The LVN conducted a physical assessment and found no physical evidence of abuse, such as bruising or redness. Despite the lack of physical evidence and the resident's inconsistent recollection of the event, the facility's policy mandates that such allegations be reported to the appropriate authorities. However, the report was not made, and the facility's abuse coordinator was not informed of the incident. Interviews with facility staff revealed a breakdown in communication and reporting procedures. The Director of Nursing and the interim administrator were unaware of the allegations, and the abuse coordinator did not receive any communication regarding the incident. The facility's policy requires that allegations of abuse be reported within 24 hours, but this was not adhered to, resulting in a failure to comply with state regulations and potentially placing residents at risk for further abuse.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring that the dumpster door was closed at all times when not in use. This deficiency was observed during a survey on September 30, 2024, at 8:15 am, when the dumpster area behind the dietary department was found with a commercial-size dumpster that was three-quarters full of garbage and had its door open. During an interview at 8:45 am on the same day, the Dietary Food Service Manager confirmed that the dumpster door should be closed when not in use to prevent vermin, pests, and insects from accessing the dumpster and potentially entering the facility. The responsibility for keeping the dumpster doors closed was shared among staff from dietary, nursing, and housekeeping departments. A review of the facility's Policies and Procedures on waste disposal, dated June 2019, indicated that waste containers should be covered and the dumpster should be closed at all times. This failure to adhere to the policy could place residents at risk of infection from improperly disposed garbage.
Failure to Document Resident's Pain Level
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically regarding the documentation of a resident's pain level. The resident, a male with multiple diagnoses including atherosclerotic heart disease, type 2 diabetes, and a lower extremity amputation, was admitted to the facility and had a care plan that included managing pain related to a skin condition. However, the pain assessment log showed inconsistent documentation of the resident's pain levels, with a significant pain level of 8 recorded at one point, but no corresponding documentation in the nurse's progress notes when pain medication was ordered. Interviews revealed that the Director of Nursing acknowledged the lack of documentation, stating that if it was not documented, it was not done. The LVN involved admitted to forgetting to document the resident's pain complaint and the subsequent call to the doctor for pain medication. The doctor confirmed that he was informed of the resident's pain and ordered Norco, but there was no documentation of the resident's pain level at that time. This lack of documentation could potentially affect the care and treatment of residents, as accurate records are crucial for managing their health needs.
Deficiency in Accurate Record-Keeping and Incident Reporting
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for two residents, which is a violation of accepted professional standards. Specifically, the facility did not correctly document the race of one resident on his Facesheet and psychiatric subsequent assessment (PSA), leading to a misidentification. Additionally, the facility did not document a resident-to-resident altercation in the incident and accident report, which is crucial for tracking and managing such incidents. Resident #2, a cognitively intact African-American male with multiple health issues, was incorrectly noted as a White male on his Facesheet and as an African-American female on his PSA. This misidentification could lead to inappropriate care and treatment. Furthermore, the facility failed to document a resident-to-resident altercation involving Resident #2 and Resident #3 in the incident and accident report, which is essential for ensuring accurate records and appropriate follow-up care. The facility's failure to document the altercation and update the care plans for both residents involved in the incident highlights a lack of proper communication and documentation procedures. The charge nurse on duty at the time of the incident only documented the resident who received the hit, not the aggressor, which is against the facility's policy. This oversight could lead to inadequate monitoring and management of residents' behaviors, potentially putting them at risk.
Non-Functional Call Light Puts Resident at Risk
Penalty
Summary
The facility failed to ensure that a resident's call light was functioning properly, which put residents at risk of not being able to call for assistance when needed. The resident, a female with multiple diagnoses including diabetes mellitus, end-stage renal disease, and legal blindness, was unable to use her call light due to a missing button. Despite having a BIMS score indicating moderate impaired cognition, the resident was aware of the issue and reported that she had been unable to use the call light for months, often having to call out for help instead. During observations and interviews, it was revealed that the nursing staff, including an RN and a CNA, were aware that the call light was within reach but did not check its functionality. The RN admitted to not assessing the call light during rounds, and the CNA, who worked PRN, was unaware of how long the call light had been non-functional. Both staff members acknowledged that the resident would not receive timely care without a working call light, and the maintenance director was not informed of the issue. The facility's policy required that call lights be accessible, functional, and routinely monitored for functionality. However, interviews with the Unit Manager, ADON, and DON indicated a lack of clarity and responsibility among staff regarding who should ensure the call light's functionality. The Administrator expected the call light to be functional and within reach, but the deficiency persisted, leaving the resident unable to call for assistance when needed.
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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