Park Village Healthcare And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Desoto, Texas.
- Location
- 207 E Parkerville Rd, Desoto, Texas 75115
- CMS Provider Number
- 455727
- Inspections on file
- 59
- Latest survey
- December 5, 2025
- Citations (last 12 mo.)
- 13 (3 serious)
Citation history
Health deficiencies cited at Park Village Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident's quarterly MDS assessment failed to document wandering behavior and incorrectly omitted a dementia diagnosis, despite multiple Elopement Wandering assessments listing dementia. The DON acknowledged errors in selecting diagnoses and stated that staff are responsible for assessment accuracy, while the administrator recognized that inaccurate records could affect assessment outcomes.
A resident with severe cognitive impairment and a history of wandering was not provided with a care plan addressing wandering behaviors until these behaviors increased and the resident was moved to memory care. Despite staff and leadership being aware of the resident's wandering, the care plan lacked measurable objectives and interventions for this issue until it escalated.
A resident with severe cognitive impairment and multiple medical conditions had routine and increased wandering behaviors that were not documented in the medical record or progress notes. Multiple elopement risk assessments incorrectly listed dementia as a diagnosis, despite the resident not having this diagnosis. The DON and Administrator confirmed these documentation errors, which were inconsistent with facility policy requiring accurate and comprehensive records.
Two residents with cognitive and psychiatric impairments were left unsupervised, resulting in one resident engaging in inappropriate sexual contact with another. Staff had previously documented escalating intrusive and aggressive behaviors by the resident, but did not implement effective supervision or interventions. The incident was not properly documented or reported to medical providers or family, and facility leadership failed to take immediate protective actions, leaving other residents at risk.
Two residents with cognitive impairment were found alone in a dining room, where one was observed by a CNA engaging in inappropriate sexual contact with the other, who was found without a brief. The facility's investigation was inconsistent and incomplete, with the Administrator and DON failing to report the incident as abuse, not notifying the medical provider, and not following the facility's abuse and neglect policy for investigation and resident protection.
Facility staff did not immediately notify a resident, the resident's physician, or the designated representative after a significant change in condition involving sexual abuse. A female resident with severe cognitive impairment was found by a CNA in a compromised state with a male resident present. The CNA reported the incident to an LVN, who notified the Administrator and performed an assessment, but no documentation or notifications to the physician or representative were made as required by facility policy. The NP was also not informed of the incident, and the designated representative confirmed they were not notified.
The facility did not report an incident where one resident was found massaging another resident's breast after removing her adult brief, despite clear evidence and policy requirements. The event was not documented in progress notes, nor was it reported to authorities or the resident's representative, and the Administrator determined it was not reportable, contrary to regulations. Both residents had significant cognitive impairments and care plans indicating vulnerability.
Two residents with severe cognitive impairment were involved in a physical altercation after one entered the other's room to retrieve personal belongings, leading to a physical assault and a scratch injury. Despite care plans addressing behavioral risks and staff training on abuse prevention, the incident was not prevented, and staff intervened only after being alerted by a vendor.
Staff failed to sanitize the food thermometer between checking different food items and did not check the temperatures of certain foods before serving them to residents. The Dietary Manager and DON confirmed that these actions could result in cross-contamination and serving undercooked food, contrary to facility policy and FDA guidelines.
Surveyors found unlocked Hoyer lifts, bed frames, and beds left in hallways, as well as a pallet with boxes stored upright near a storage closet, creating fall and injury concerns. Interviews with CNAs, an LVN, the DON, and other staff revealed inconsistent practices and unclear responsibility for securing and storing equipment, contrary to the facility's stated commitment to a safe and comfortable environment.
A medication cart on one hall was left unlocked and unattended for several minutes, with no staff present and the drawers facing the hallway. An LVN acknowledged not locking the cart before leaving to assist a resident, and staff interviews confirmed that carts should be locked when not in use. Facility policy requires all drugs and biologicals to be stored in locked compartments accessible only to authorized personnel.
A resident with moderate cognitive impairment and multiple diagnoses was unable to file grievances anonymously due to the facility's process requiring forms to be obtained from the receptionist, limiting access. Staff interviews revealed confusion about the grievance process, and observations confirmed that anonymous filing was not possible, contrary to facility policy.
A facility failed to maintain an effective infection control program, resulting in a gastrointestinal outbreak affecting numerous residents. Symptomatic individuals were not isolated, participated in group activities, and shared rooms with non-symptomatic residents. Staff did not consistently use proper PPE or follow hand hygiene protocols during care, and the outbreak was not reported to local authorities. These failures led to the spread of infection among residents, including those with cognitive impairments and high care needs.
A resident with a history of stroke and communication difficulties experienced ongoing tooth pain that was managed with pain medications, but there was a significant delay in arranging a dental referral and appointment. Despite documentation of pain and a care plan addressing communication barriers, the referral process was not initiated promptly due to lapses in communication between nursing staff and the social worker. The resident was not seen by dental services until more than a month after the initial complaint.
Three residents with cognitive and physical impairments did not receive necessary nail care, resulting in long and dirty fingernails despite care plans and facility policy requiring regular cleaning and trimming. Staff interviews confirmed that CNAs and nurses were responsible for this care, but it was not provided as needed.
Surveyors found that two medication carts contained controlled medications with broken blister pack seals, and staff failed to report or discard the affected pills as required by facility policy. Both a CMA and an LVN were unaware of when the seals became broken, and the DON confirmed that such medications should have been discarded to prevent errors or diversion.
Surveyors found that two residents' bathroom call light systems were either inaccessible or missing, with one pull string wrapped around a grab bar and another missing entirely, leaving residents unable to call for assistance if needed. Interviews with the maintenance supervisor, DON, and Administrator confirmed awareness of the issue and the facility's policy requiring accessible call systems.
A shared bathroom used by two residents had an ongoing water leak from under the toilet, with water spreading across the floor to the shower drain. The Maintenance Director and other staff were unaware of the leak, and required procedures such as reporting the hazard and placing wet floor signage were not followed, resulting in unsanitary and unsafe conditions.
A resident with severe cognitive impairment was struck in the right eye by another cognitively impaired resident, resulting in bruising. The incident occurred in front of the nursing station and was witnessed and interrupted by a CNA. Both residents were assessed, and the event was reported to facility leadership, but not further reported due to lack of perceived intent. Facility policy addresses abuse prevention and monitoring of aggressive behaviors.
Two residents with severe cognitive impairment were involved in an altercation resulting in a bruise, which was witnessed and internally reported by staff but not reported to the State Survey Agency as required by facility policy. The DON and Administrator determined not to report the incident externally due to lack of intent and memory of the event by the residents, leading to a deficiency in abuse reporting procedures.
A resident with severe cognitive impairment and multiple medical conditions was found with the call light out of reach, contrary to facility policy. Staff interviews confirmed the importance of ensuring call light accessibility to prevent risks such as falls and injuries. The facility's policy requires the call device to be within reach before staff leave the room.
A resident with severe cognitive impairment and an indwelling suprapubic catheter was found with their catheter drainage bag resting on the floor, contrary to facility guidelines. Staff interviews confirmed the importance of keeping the bag off the floor to prevent infections, highlighting a lapse in catheter care that posed a risk to the resident.
A resident with a suprapubic catheter was not provided care in accordance with Enhanced Barrier Precautions (EBP) due to a failure by an LVN to wear the required PPE, specifically a gown. The facility lacked proper signage and PPE supplies, despite policies requiring these measures for residents with indwelling devices to prevent the spread of infections. Interviews confirmed the oversight, highlighting a lapse in infection control practices.
The facility failed to maintain a safe environment for five residents due to an ant infestation in their rooms. Despite reports of ants on residents and in their beds, there was inconsistent documentation and follow-up. The pest control measures were inadequate, leading to recurring ant sightings and a lack of coordination among staff to address the issue effectively.
A facility failed to maintain a safe environment by not adequately addressing an ant infestation in resident rooms, affecting five residents. Despite reports of ants on residents and in their rooms, there was inconsistent documentation and follow-up. Staff interviews revealed a lack of awareness and communication about the issue, and the facility lacked a clear incident policy.
The facility failed to document incidents involving black ants found in the rooms and beds of five residents, leading to incomplete medical records. Despite reports from residents and family members, the nursing staff did not complete incident reports, skin assessments, or progress notes. Interviews revealed inconsistencies in reporting practices, with some staff unaware of the incidents and others not following documentation procedures.
A deficiency in the pest control program at a facility led to black ants infesting several residents' rooms. Despite reports and some treatments, there were inconsistencies in documentation and communication among staff. Residents experienced ants on their bodies and in their beds, but follow-up actions like skin assessments were not consistently performed. Maintenance and housekeeping staff attempted to address the issue, but challenges in communication and procedure implementation persisted.
A treatment cart was found unlocked and unattended in a hallway, containing various medical supplies. Nurse A, responsible for the cart, indicated it was left unlocked by the previous shift. Interviews with staff, including the ADON, DON, and Administrator, acknowledged the risk of residents accessing unauthorized medications. The facility's policy requires all drugs to be stored in locked compartments, accessible only to authorized personnel.
A facility failed to administer medications properly to a resident with dementia, depression, and diabetes. Observations revealed pills on the floor, indicating the resident did not receive all prescribed medications. The MA responsible did not verify if the resident swallowed the pills, and the DON acknowledged the risk of worsening conditions due to missed doses.
A resident with multiple medical conditions requiring Enhanced Barrier Precautions (EBP) did not receive care in accordance with infection control protocols. Two CNAs failed to wear the necessary PPE, such as gowns, during high-contact care activities, despite signage indicating the requirement. The Director of Nursing acknowledged the risk of infection spread due to non-compliance, and the facility's infection prevention policy lacked guidance on EBP.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected their status, specifically regarding wandering behavior and dementia diagnosis. The quarterly Minimum Data Set (MDS) assessment did not document wandering behaviors in Section E, despite other records, such as the quarterly Elopement Wandering assessments, repeatedly listing dementia as a diagnosis for the resident. The resident's face sheet did not include dementia as a diagnosis, and the resident had a BIMS score indicating severe cognitive impairment. The discrepancy between the MDS and other assessments, as well as the inconsistent documentation of dementia, was identified during record review and interviews. During interviews, the DON acknowledged that dementia was incorrectly selected as a diagnosis on multiple Elopement Wandering assessments and admitted to not being aware of her own error in selecting dementia on one of the assessments. The DON also stated that whoever completed the assessment was responsible for its accuracy and recognized that incorrect documentation could affect assessment outcomes. The administrator, lacking a clinical background, also noted that inaccurate information in the electronic record could impact assessment results. Facility policy requires comprehensive and accurate assessments, but this was not followed in this instance.
Failure to Address Resident Wandering in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for a resident with multiple complex diagnoses, including heart failure, schizoaffective disorder, insomnia, dysphagia, repeated falls, type 2 diabetes, hypertension, muscle weakness, and cognitive communication deficit. Despite a history of wandering behavior, the resident's care plan did not address wandering until a significant increase in wandering was observed, at which point the resident was moved to memory care and the care plan was updated. Prior to this, the care plan lacked measurable objectives and timeframes to address the resident's wandering, even though staff and leadership were aware of the behavior. Interviews with the DON, Administrator, and staff confirmed that the resident had a longstanding pattern of wandering within the facility, which had recently escalated to include entering other areas such as resident rooms and administrative offices. The omission of wandering from the care plan meant that staff may not have been fully informed of the resident's behaviors or the best interventions to use. Facility policy required that assessment information be used to develop and revise comprehensive care plans, but this was not followed in the case of this resident until the behavior became more pronounced.
Failure to Accurately Document Resident Wandering and Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple complex diagnoses, including heart failure, schizoaffective disorder, insomnia, dysphagia, repeated falls, type 2 diabetes, essential hypertension, muscle weakness, and cognitive communication deficit. Despite the resident exhibiting routine wandering behaviors since admission and an increase in wandering 2-4 weeks prior to a specific date, these behaviors were not documented in the resident's electronic medical record or progress notes. The care plan did not address wandering until a later date, and incident logs did not reflect any wandering incidents. Quarterly Minimum Data Set (MDS) assessments consistently indicated severe cognitive impairment but did not document wandering behaviors or a diagnosis of dementia. However, multiple quarterly elopement risk assessments incorrectly listed dementia as a diagnosis, despite the resident not having this diagnosis according to the MDS and statements from the DON. The DON acknowledged that the incorrect selection of dementia could affect the outcome of risk assessments and that wandering behaviors should have been documented in all relevant assessments and progress notes. Interviews with the DON and Administrator confirmed that the lack of documentation regarding the resident's wandering was an oversight, with the DON attributing it to staff possibly not paying attention or accidentally selecting the wrong diagnosis. Both acknowledged that the responsibility for accurate documentation lay with the staff completing the assessments and that the facility's policies required comprehensive and accurate documentation of resident care, assessments, and behaviors.
Failure to Prevent and Respond to Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse and neglect, specifically failing to prevent inappropriate sexual behavior between them. One resident with severe cognitive impairment and another with moderate cognitive impairment and a history of psychiatric issues were left unsupervised in the dining room, where a certified nursing assistant (CNA) observed one resident massaging the breast of the other over her clothing. The CNA also noted that the female resident's bra was around her waist and she was not wearing a brief. Prior to this incident, the male resident had been documented as exhibiting increasingly erratic and intrusive behaviors, including entering other residents' rooms, being verbally aggressive, and being difficult to redirect. These behaviors were noted by multiple staff members and documented in progress notes, but no effective interventions or increased supervision were implemented to address the escalating risk. Despite clear documentation of the male resident's behavioral changes and repeated incidents of him entering other residents' rooms, staff did not provide adequate supervision or take preventive measures. The incident in the dining room was not properly documented in the residents' progress notes, and there was no notification to the physician or the designated representative regarding the sexual abuse incident. The facility's incident reports for the relevant period did not include this event, and the initial internal investigation discounted the CNA's account due to perceived inconsistencies, leading to a determination that no abuse had occurred. As a result, both residents remained on the same locked unit without additional monitoring or safeguards in place. Interviews with staff and review of facility records revealed a lack of immediate protective actions and failure to follow abuse prevention policies. The administrator and DON did not take action after being notified of the incident, and the male resident was not placed under increased supervision until after the event was identified by surveyors. The nurse practitioner was not informed of the potential sexual abuse, and there was no evidence of timely or appropriate notification to medical providers or family members. This series of inactions and failures to document, report, and intervene placed other residents at risk of abuse and neglect.
Failure to Investigate and Respond to Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate and respond to an allegation of inappropriate sexual behavior between two residents. One resident with severe cognitive impairment and another with moderate cognitive impairment and a history of psychiatric illness were found alone in the dining room, where a certified nursing assistant (CNA) observed one resident massaging the other's chest and discovered that the cognitively impaired female resident's brief was removed. The CNA intervened, removed the female resident from the situation, and notified the nurse. The incident was reported to the Director of Nursing (DON) and the Administrator, but the subsequent investigation was inconsistent and incomplete. The facility's investigation did not include a thorough review of the incident. The CNA's written and verbal statements were inconsistent, and the Administrator and DON determined that nothing had happened between the residents based on this discrepancy, despite physical evidence such as the removed brief and the residents being alone together. The Administrator described the investigation as a "soft investigation" and did not report the incident as abuse, nor did they notify the nurse practitioner of the potential sexual abuse. The medical provider was not informed of the incident until after state surveyors were present in the facility. Additionally, the facility did not separate the residents or provide increased supervision immediately following the incident, as required by their own abuse and neglect policy. The facility's policy required immediate and thorough investigation of all allegations of abuse, including interviews, medical assessments, and documentation. However, the investigation lacked key elements such as interviews with all relevant staff, timely notification of the medical provider, and adequate protection of the alleged victim. The failure to follow policy and thoroughly investigate the incident placed residents at risk for abuse and neglect, and led to the identification of Immediate Jeopardy by surveyors.
Failure to Notify Physician and Representative After Resident Sexual Abuse Incident
Penalty
Summary
Facility staff failed to immediately inform a resident, the resident's physician, and the designated representative following a significant change in the resident's condition involving an incident of sexual abuse. The incident involved a female resident with severe cognitive impairment and a history of senile degeneration of the brain, who was found by a CNA in the dining room with her bra around her waist and without a brief, while a male resident with moderate cognitive impairment and a history of brain compression and schizophrenia was present. The CNA observed the male resident massaging the female resident's breast over her blouse and holding her undergarments. The CNA reported the incident to an LVN, who then notified the Administrator and performed a skin assessment on the female resident, finding no injuries or distress at that time. Despite the incident, there was no documentation in the progress notes regarding the event, nor was there any notification to the physician or the designated representative of the female resident. The LVN stated she was instructed by the DON to wait for clarification from the Administrator before documenting the incident or notifying the physician and family. The Administrator later acknowledged that the nurse was supposed to notify medical staff, the designated representative, the DON, and Administration, but this did not occur due to improper education of the nurse. The DON was uncertain about who made the decision not to notify the designated representative, and the designated representative confirmed they had not been informed of the incident. The nurse practitioner (NP) for the residents was also not notified of the potential sexual abuse and only became aware of a significant event when informed that state surveyors were present in the facility. The facility's policy required licensed nurses to inform family or responsible parties of changes in condition and to document all nursing actions, physician contacts, and resident assessments in the nursing progress notes. These steps were not followed in this case, resulting in a failure to meet notification and documentation requirements after a significant change in a resident's condition.
Failure to Timely Report Alleged Sexual Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation was made. Specifically, the facility did not report an incident involving two residents, where one was found massaging the breast of another after removing her adult brief, to local law enforcement or the State Survey Agency as required. The incident was observed by a CNA, who found the two residents alone in the dining room, with one resident's bra around her waist and her brief missing, while the other resident was holding the brief. The CNA intervened, ensured the resident was dressed, and notified the nurse, who then informed the Administrator. Record reviews revealed that there was no documentation of the sexual incident in the progress notes, nor was there any documentation of notification to the doctor or the designated representative. The Administrator conducted what he described as a "soft investigation" and determined that the incident was not reportable, despite the circumstances and the facility's own abuse and neglect policy, which requires immediate reporting of such allegations. The Administrator stated that he could not assume anything had happened between the residents because there were no witnesses, even though the CNA's account and the video evidence indicated otherwise. The residents involved had significant cognitive impairments and care plans that identified risks such as impaired mobility, self-care deficits, and potential for aggressive behaviors. The facility's failure to report the incident as required by policy and regulation resulted in a deficiency, as it did not follow established procedures for reporting suspected abuse, neglect, or exploitation to the appropriate authorities within the mandated timeframe.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that a resident was free from abuse when an altercation occurred between two residents, resulting in one resident sustaining a scratch on his nose. Both residents involved had severe cognitive impairment and a history of dementia and cerebrovascular accidents, with one resident also experiencing hemiplegia. The incident took place when one resident entered the other's room, reportedly to retrieve personal belongings he believed were left there, as it had previously been his room. The resident occupying the room was asleep, became startled upon awakening to find someone going through his belongings, and responded by physically assaulting the other resident, including punching and overturning his wheelchair. Prior to the incident, both residents had been roommates and reportedly got along well, but one had requested a room change, which was accommodated. There was no documented history of aggression between the two residents before this event. The care plans for both residents included interventions for managing physical behaviors and aggression, such as 1:1 monitoring, psychiatric consults, and de-escalation techniques. However, at the time of the incident, these interventions did not prevent the altercation from occurring, and the staff were alerted to the situation by a vendor who witnessed the fight. Upon arrival, staff found one resident on the floor and the other actively hitting him. The staff separated the residents and assessed the injured resident, who was found to have a bleeding scratch on his nose. Interviews with staff and review of records confirmed that the residents had not previously exhibited aggressive behavior toward each other or other residents. The facility's policy required separation of residents involved in altercations and ongoing assessment, but the incident demonstrated a failure to protect the resident from abuse as required.
Failure to Sanitize Thermometer and Check Food Temperatures in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen operations. During breakfast service, the cook did not sanitize the food thermometer between checking different food items, instead wiping it with a rag that was sitting on a cart. The cook also did not check the temperatures of certain foods, including cinnamon rolls, biscuits, and fried eggs, before serving them to residents. The cook stated that alcohol swabs were not available at the time, and the Dietary Manager confirmed that swabs should have been present in the kitchen. The Dietary Manager also acknowledged that not sanitizing the thermometer between uses could expose residents to bacteria and infection, and that not checking food temperatures could result in serving undercooked food. Record review showed that the facility's policy requires prevention of food contamination to avoid foodborne illness, and FDA guidelines emphasize the importance of using a food thermometer to ensure food safety. Interviews with the Dietary Manager and DON confirmed that these lapses in procedure could lead to cross-contamination and serving inadequately cooked food. The report also referenced a recent incident involving undercooked chicken being served to a resident, further highlighting the failure to follow safe food handling practices.
Failure to Secure Equipment and Maintain Safe Hallways
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in two of three halls reviewed. On multiple occasions, surveyors observed unlocked Hoyer lifts, bed frames, and beds left in the hallways of Halls 100 and 400. Additionally, a pallet with boxes was found upright against a wall near a storage supply closet. These items were not properly secured or stored, creating potential fall and injury concerns for residents. Interviews with CNAs, an LVN, the DON, the Central Supplies Coordinator, the Maintenance Director, and the Administrator revealed inconsistent understanding and practices regarding responsibility for securing and storing equipment. Staff members variously stated that CNAs, nursing staff, or everyone was responsible for locking and storing Hoyer lifts and other equipment after use. The Central Supplies Coordinator and Maintenance Director described their roles in removing pallets and boxes, but acknowledged that these items were sometimes left in hallways. The facility's admission packet indicated residents have a right to a safe, clean, comfortable, and homelike environment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency occurred when a medication cart on Hall 400 was left unlocked and unattended for approximately five minutes in front of the nurse's station. The drawers of the cart faced the hallway, and no staff were present in the area during this time. LVN A was observed walking by the cart, pressing the lock closed, and then leaving the hall with a resident, but the cart remained unlocked. No residents or visitors were in the immediate area at the time of the observation. Interviews with staff confirmed that the medication cart should be locked when not in use to prevent unauthorized access. LVN A acknowledged that she should have locked the cart before leaving to check on a resident who had returned from dialysis. The DON also stated that medication carts must be locked to prevent drug diversion and unauthorized access. Review of the facility's policy indicated that all drugs and biologicals are to be stored in locked compartments, accessible only to authorized personnel.
Failure to Provide Anonymous Grievance Filing Process
Penalty
Summary
The facility failed to ensure that a resident had access to file grievances anonymously, as required by policy. Record review showed that all grievances for the resident were not filed anonymously, and the resident reported not knowing where grievance forms were located or how to file a grievance anonymously. The resident, who had a history of stroke and diabetes and was moderately cognitively impaired, kept a personal notebook of complaints and relied on staff to make copies, but felt her concerns were not addressed. Interviews with staff revealed uncertainty about whether grievances had been filed for the resident and indicated that grievance forms were only available through the receptionist, limiting anonymous access. Further interviews confirmed that there was no established process for residents to file grievances anonymously, and the social worker, who served as the grievance official, stated that residents could only report concerns directly to her or through staff. Observations showed that blank grievance forms were kept at the receptionist desk and were not freely accessible to residents without staff assistance. The facility's policy required making information on filing grievances available to residents, but this was not effectively implemented, resulting in the deficiency.
Failure to Implement and Maintain Infection Control Program During GI Outbreak
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in an outbreak of suspected norovirus among residents. Surveyors found that the facility did not identify the outbreak in a timely manner, did not isolate symptomatic residents, and allowed residents with gastrointestinal symptoms to participate in group activities and dine with others who were not ill. Additionally, symptomatic residents were housed in rooms with non-symptomatic residents, and proper cleaning and decontamination of infected rooms was not performed. The facility also failed to report the outbreak to local authorities and did not have a system in place to evaluate or screen employees for symptoms such as nausea, vomiting, and diarrhea. Direct observations and record reviews revealed multiple instances where staff did not follow standard infection control practices. For example, a CNA failed to change gloves and perform hand hygiene during incontinence care for a resident, and another CNA did not wear appropriate PPE when providing care to a resident on enhanced barrier precautions. During wound care for a resident on enhanced barrier precautions, the ADON did not don the required PPE. These lapses in infection control were observed despite the presence of signage and available supplies for PPE outside resident rooms. Staff interviews indicated a lack of awareness or adherence to infection control protocols, with some staff denying the presence of symptoms among residents despite documentation to the contrary. The outbreak affected a significant number of residents, with documentation showing multiple cases of nausea, vomiting, and diarrhea over several days. Physician orders for symptomatic treatment were given, but isolation and transmission-based precautions were inconsistently implemented. Residents with cognitive impairments and those dependent on staff for care were among those affected. The facility's failure to implement and train staff on transmission-based precautions, as well as to maintain surveillance and reporting systems, contributed to the spread of infection and placed residents at risk for further complications.
Delay in Dental Referral and Care for Resident with Tooth Pain
Penalty
Summary
The facility failed to provide timely routine and 24-hour emergency dental care for a resident who began experiencing tooth pain. The resident, a male with a history of stroke, cognitive communication deficit, and unspecified pain, reported tooth pain starting on 02/11/25. Despite ongoing complaints of tooth pain, which were documented in the medical record and managed with pain medications such as acetaminophen and tramadol, there was a significant delay in arranging a dental referral and appointment. The resident's care plan included monitoring for nonverbal indicators of discomfort due to expressive aphasia and slurring, and staff documented multiple instances of tooth pain and administration of pain medication. Although the nurse practitioner was notified and a dental referral was ordered, the referral process was not completed in a timely manner. The social worker, responsible for dental referrals, was not made aware of the resident's dental pain in February and only initiated the referral process after being informed in March. The dental referral was faxed on 03/14/25, and the resident was seen by dental services on 03/21/25, more than a month after the initial complaint of tooth pain. Interviews with nursing staff and the social worker confirmed that communication lapses contributed to the delay in the referral process. The facility's policy required timely arrangements for outside services, but the resident did not receive prompt dental care as required. The delay in providing dental services was acknowledged by both the social worker and the administrator, who stated that referrals should typically be completed within a few days.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for three residents who were dependent on staff for care. Observations and interviews revealed that these residents had excessively long and dirty fingernails, with dark or black substances underneath, indicating a lack of routine nail care. Staff interviews confirmed that nail care, including cleaning and trimming, was the responsibility of CNAs unless the resident had diabetes, in which case nurses were responsible. However, the required care was not provided as needed. Resident assessments showed that all three residents had significant cognitive and/or physical impairments, requiring extensive or maximal assistance with personal hygiene. Care plans for these residents included interventions for staff to provide the necessary level of physical assistance with ADLs, but these interventions were not consistently implemented. Observations on multiple dates confirmed that the residents' fingernails were not maintained according to facility policy or care plan expectations. Interviews with CNAs, an LVN, and the DON confirmed that nail care should be performed regularly and as needed, and that failure to do so could pose risks such as infection or skin breakdown. The facility's own policy required routine cleaning and inspection of nails during ADL care, with additional care provided as needed, but this was not followed for the residents in question.
Failure to Discard Controlled Medications with Broken Seals
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to ensure the proper handling of controlled medications on two medication carts. Specifically, surveyors observed that blister packs containing controlled medications—Clobazam 20 mg for one resident and Tylenol with Codeine #4 for another—had broken seals with the pills still inside. In both cases, the medication count sheets matched the physical count, but the staff members responsible (a CMA and an LVN) were unaware of when the blister pack seals became broken. Both staff members acknowledged that the medication should have been discarded if the seal was broken, as per facility policy, but this was not done. Interviews with the staff and the DON confirmed that the expectation was for any medication with a broken seal to be discarded to prevent potential diversion or medication errors. The DON stated that charge nurses are responsible for checking medication carts daily for such issues during shift counts. The facility's policy also indicated that deteriorated or compromised drugs should not be used and must be returned or destroyed. Despite these policies, the failure to promptly identify and report the damaged blister packs resulted in the continued storage of potentially compromised controlled medications.
Inaccessible and Missing Call Light Systems in Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to ensure the call light system was accessible in two residents' bathroom areas. In one room, the call light pull string was found entwined around a grab bar fixture, positioned two feet from the floor, making it inaccessible to a resident lying on the floor. In another room, the call light pull string was missing entirely, and the call light outlet did not have a push button, leaving no means for a resident to activate the system from the bathroom. Interviews with the maintenance supervisor confirmed that it was his responsibility to ensure the call lights were fixed and accessible, and he acknowledged that missing or inaccessible call light strings could prevent residents from calling for help. The DON and Administrator both stated that any issues with the call light system should be reported to maintenance and fixed, and recognized the risk to residents if they are unable to communicate their needs. Facility policy requires that residents have a means of communication with nursing staff, but this was not met in the observed cases.
Failure to Address Bathroom Water Leak and Maintain Sanitary Environment
Penalty
Summary
A deficiency was identified in the facility's failure to maintain a sanitary, orderly, and comfortable environment in one of the resident rooms. Specifically, a shared bathroom in room 301, used by two residents, was observed to have a water leak coming from underneath the toilet seat, with water crossing in front of the sink and going to the shower drain. The Maintenance Director confirmed the leak was from under the toilet tank after flushing the toilet and stated he was previously unaware of the issue. He also noted that his staff perform monthly water flushes and room checks but had not identified this leak. Interviews with staff, including an LVN, the DON, and the administrator, revealed that none were aware of the water on the bathroom floor prior to the surveyor's observation. The facility's policy requires staff to report such hazards, log them in the maintenance system, and place wet floor signage, but these actions were not taken. The presence of water on the floor was not reported or addressed, resulting in a failure to provide necessary housekeeping and maintenance services to ensure a clean and safe environment for the residents.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment was physically struck in the right eye by another resident, also with severe cognitive impairment, resulting in bruising. The incident took place in front of the nursing station, where a CNA intervened and separated the two residents. Both residents were assessed by an LVN, who noted the injury to the victim and reported the incident to the medical director, ADON, and DON. Interviews with staff revealed that the incident was not immediately recalled by the LVN until she reviewed her notes. The CNA confirmed witnessing the altercation and intervening promptly. Both residents involved were unable to recall the incident during interviews conducted the following day, and no other altercations between them were reported by staff. The DON and Administrator reviewed the incident and determined it was not reported further because they did not identify intent to injure. Facility policy defines abuse as the willful infliction of injury, and the policy includes measures for identifying and monitoring residents with behaviors that could lead to conflict, such as physical aggression. The failure to protect the resident from physical abuse by another resident was identified as a deficiency.
Failure to Immediately Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report an alleged act of physical abuse involving two residents with severe cognitive impairment. According to interviews and record review, an altercation occurred in front of the nursing station where one resident struck another, resulting in a bruise under the right eye of the resident who was hit. The incident was witnessed by a CNA, who separated the residents, and was subsequently assessed by an LVN. The LVN reported the incident internally to the MD, ADON, and DON, but no external report was made to the State Survey Agency as required. The DON and Administrator reviewed the incident and decided not to report it externally, citing a lack of identifiable intent to injure and the residents' inability to recall the event. Facility policy, however, requires all allegations of abuse or neglect to be reported to appropriate state or federal agencies within specified timeframes. The failure to report the incident externally constituted a deficiency in the facility's abuse reporting procedures.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light system was within reach, which is a necessary accommodation for the resident's needs and preferences. The resident, a male with severe cognitive impairment and multiple medical conditions including neurogenic bladder, multiple sclerosis, and hemiplegia, was observed lying in bed with the call light placed on top of the nightstand, out of reach. This oversight was noted during an observation and interview with an LVN, who acknowledged the call light should always be within the resident's reach to prevent risks such as falls and injuries. Interviews with the LVN, the Director of Nursing (DON), and the Administrator confirmed that it is the responsibility of all staff to ensure the call light is accessible to residents before leaving the room. The facility's policy, revised in 2007, also mandates that the call device be placed within the resident's reach. The failure to adhere to this policy could result in residents being unable to communicate their needs and receive timely assistance, as emphasized by the staff and administration during the interviews.
Inadequate Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with severe cognitive impairment and multiple medical conditions, including neurogenic bladder and multiple sclerosis. The resident, who was totally dependent on staff for activities of daily living, had an indwelling suprapubic catheter. The facility's comprehensive care plan and physician orders required that the catheter drainage bag be kept below the level of the bladder and off the floor to prevent urinary tract infections. However, during an observation, the resident's catheter drainage bag was found resting on the floor while the resident was lying in bed. Interviews with facility staff, including an LVN and the Director of Nursing, confirmed that the catheter drainage bag should be kept off the floor to prevent infection. The LVN acknowledged the risk of infection due to the drainage bag's position and noted the challenge of maintaining the bed at a low position due to the resident's fall risk. The facility's infection control policy also emphasized the importance of keeping the catheter tubing below the bladder level. Despite these guidelines, the failure to maintain the catheter drainage bag off the floor was observed, posing a risk of infection to the resident.
Inadequate Infection Control Practices for Resident with Indwelling Device
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during the care of a resident with a suprapubic catheter. The resident, who has a history of cerebral palsy, neurogenic bladder, and mild intellectual disabilities, was on Enhanced Barrier Precautions (EBP) due to the presence of an indwelling medical device. Despite this, LVN A did not wear the required personal protective equipment (PPE), specifically a gown, while providing care. This oversight occurred even though the facility's policy mandates the use of gown and gloves for high-contact care activities to prevent the transmission of multi-drug resistant organisms (MDROs). The deficiency was further compounded by the absence of signage and PPE supplies outside or inside the resident's room, which should have indicated the need for EBP. Interviews with LVN A and the Director of Nursing (DON) confirmed the lapse in protocol, with LVN A acknowledging the failure to don the appropriate PPE and the DON emphasizing the importance of EBP for residents with indwelling devices. The facility's administrator also noted the lack of signage and supplies, despite a recent in-service training on EBP. This failure placed residents at risk of exposure to infectious agents, as the facility did not adhere to its infection control policies.
Ant Infestation in Resident Rooms
Penalty
Summary
The facility failed to provide a safe environment for five residents, as their rooms were infested with black ants over a period of several weeks. The presence of ants was noted in the rooms of these residents, with some residents reporting ants on their bodies and in their beds. Despite the residents' complaints and observations by staff and visitors, there was a lack of consistent documentation and follow-up actions to address the ant infestation effectively. Resident #1, a male with multiple health conditions including anemia, renal insufficiency, and hemiplegia, reported having ants all over him while in bed. Although the room was sprayed and cleaned, there was no documentation of a thorough assessment or notification to department heads. Similarly, Resident #2, a female with heart failure and multiple sclerosis, reported being bitten by ants, but there was no documentation of a skin assessment or follow-up actions in her nurse progress notes. The facility's pest control measures were inadequate, as evidenced by the recurring ant sightings in multiple residents' rooms. Maintenance and housekeeping staff were notified of the ant problem, but there was a lack of coordination and communication among staff members, leading to inconsistent responses to the infestation. The facility's pest control policy was not effectively implemented, resulting in a failure to maintain a safe and comfortable environment for the residents.
Ant Infestation in Resident Rooms
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards, specifically concerning the presence of black ants in the rooms and beds of five residents. These residents, who were reviewed for incident accidents, were exposed to potential risks of ant bites, which could lead to skin irritation, infection, and pain. The nursing staff did not adequately address the ant infestation, as evidenced by multiple reports from residents and family members about ants in their rooms and on their bodies. Despite some actions taken, such as spraying and cleaning, there was a lack of consistent documentation and follow-up assessments. Resident #1, a male with multiple health conditions including anemia, renal insufficiency, and hemiplegia, reported ants on his body, but no bites were noted. Resident #2, a female with heart failure and multiple sclerosis, stated she was bitten by ants, yet there was no documentation of a skin assessment or notification to department heads. Resident #3, a male with cancer and cognitive impairment, had ants observed on his bed by a visitor, but no documentation was found in his progress notes. Resident #4, a male with hypertension and diabetes, reported ants from his AC unit and had a rash on his elbow, but there was no mention of ant bites in his records. Resident #5, a male with severe cognitive impairment and multiple health issues, had ants on his bed, but no bites were found upon assessment. Interviews with staff, including LVNs, RNs, and the DON, revealed a lack of awareness and communication regarding the ant problem. The DON acknowledged hearing about ants in some residents' rooms but was unaware of others. The Administrator was also not fully informed about the extent of the issue. The facility lacked a clear incident/accident policy, and there was no consistent procedure for documenting and addressing the ant sightings, leading to inadequate supervision and potential harm to residents.
Failure to Document Ant Incidents and Assessments
Penalty
Summary
The facility failed to maintain accurate and complete medical records for five residents, specifically regarding incidents involving black ants found in their rooms and beds. The nursing staff did not complete incident reports, skin assessments, or nurse progress notes after these incidents, which were reported by residents and their family members. This lack of documentation was observed for residents who had various medical conditions, including anemia, renal insufficiency, diabetes, and cognitive impairments. For instance, one resident reported having ants all over him while in bed, but no incident report or skin assessment was documented. Another resident stated she was bitten by ants, yet there was no follow-up documentation in her medical records. Similarly, other residents had ants in their rooms, but the facility's records did not reflect any assessments or incident reports, despite reports from family members and staff observations. Interviews with staff revealed inconsistencies in reporting and documentation practices. Some staff members were unaware of the ant incidents, while others acknowledged the presence of ants but did not complete the necessary documentation. The Director of Nursing and other staff members indicated that incident reports were not completed unless there was an actual injury, and there was a lack of clarity on the procedures for documenting such incidents. The facility's documentation policy emphasized the importance of maintaining accurate records, but this was not adhered to in these cases.
Deficiency in Pest Control Program Leads to Ant Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of black ants in the rooms of several residents over a period of time. The pest control issues were documented in the facility's records, with sightings and treatments recorded for specific rooms. However, there were inconsistencies in the reporting and documentation of these sightings, as not all instances were logged or communicated effectively among staff members. Residents reported seeing ants in their rooms, with some experiencing ants on their bodies or in their beds. Despite these reports, there were gaps in the follow-up actions taken by the staff, such as conducting thorough skin assessments or notifying relevant department heads. Interviews with residents and family members revealed that while some rooms were treated for ants, there was a lack of consistent communication and documentation regarding the presence of ants and the steps taken to address the issue. The facility's maintenance and housekeeping staff acknowledged the ant problem and attempted to address it by spraying affected areas and advising staff on preventive measures. However, there were challenges in ensuring that all staff members were aware of the cleaning tools available and the procedures to follow when ants were sighted. The facility's pest control policy outlined responsibilities and preventive measures, but the implementation of these guidelines was inconsistent, leading to the deficiency in maintaining a pest-free environment for the residents.
Unlocked Treatment Cart Poses Risk
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an observation of Treatment Cart #1 being left unlocked and unattended in the 100 Hall area. This incident occurred in the presence of four residents, with no staff having visibility of the cart. The cart contained various items, including hydrogen peroxide, saline, alcohol wipes, ketoconazole shampoo, nystatin topical powder, zinc oxide ointment, and hydrocortisone cream. Nurse A, who was responsible for the cart, stated that she had not used it since starting her shift and suggested that it was left unlocked by the nurse from the previous overnight shift. Interviews with facility staff, including Nurse A, ADON B, DON C, and Administrator D, highlighted the risks associated with leaving treatment carts unlocked and unattended. These risks included residents potentially accessing unauthorized medications or ingesting non-consumable items, which could be detrimental to their health. The facility's policy, revised in July 2023, mandates that all drugs and biologicals be stored in locked compartments and accessible only to authorized personnel. Despite this policy, the incident demonstrated a lapse in adherence, as the treatment cart was not secured as required.
Failure to Administer Medications Properly
Penalty
Summary
The facility failed to provide routine and emergency drugs and biologicals to a resident, as evidenced by the failure to administer all of the resident's medications. The resident, an elderly male with diagnoses including dementia, depression, and diabetes, was admitted to the facility and required assistance with all activities of daily living. During an observation, a pink and turquoise pill, identified as the resident's Fluoxetine, was found on the floor near the nurse station. The medication aide (MA-A) responsible for administering the medication admitted to placing the pills in the resident's mouth using a spoon but did not check the resident's mouth to ensure the pills were swallowed. Further observation revealed another unidentifiable white pill on the floor, which appeared to have been in a resident's mouth. The Director of Nursing (DON) acknowledged the risk of the resident not receiving his medications, which could lead to worsening depression and behavioral problems. The facility's policy on the administration of drugs requires medications to be administered according to the physician's written orders and documented if withheld, refused, or given at a different time. However, the failure to ensure the resident took his medications as prescribed was evident in this case.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA-B and CNA-C who did not adhere to the required Enhanced Barrier Precautions (EBP) when providing care to a resident. The resident, a female with a history of brain damage, cardiac arrest, and a blood clot in the lungs, was totally dependent on staff for all activities of daily living and had multiple medical conditions including a tracheostomy, pneumonia, an indwelling urinary catheter, and a feeding tube. Despite the presence of signage indicating the need for PPE, both CNAs only wore gloves and failed to use gowns during high-contact care activities, which was a requirement under EBP due to the resident's condition. The deficiency was further highlighted by the observation that CNA-B picked up a foam wedge from the floor and used it to position the resident, potentially increasing the risk of infection transmission. Interviews with the CNAs revealed a lack of compliance with the facility's infection control policy, as CNA-B did not initially intend to provide care and CNA-C did not wear PPE when assisting. The Director of Nursing confirmed that EBP was necessary to minimize infection spread among residents with infections, catheters, and other medical devices, and acknowledged the risk posed by not following PPE protocols. The facility's infection prevention policy, dated October 2022, did not address Enhanced Barrier Precautions, contributing to the deficiency.
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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