Pebble Creek Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 11608 Scott Simpson Dr, El Paso, Texas 79936
- CMS Provider Number
- 455718
- Inspections on file
- 42
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Pebble Creek Nursing Center during CMS and state inspections, most recent first.
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 moderate cognitive impairment and arthritis, care planned for assistance with personal hygiene including shaving as needed, was observed with noticeable facial hair on the upper lip and chin, stating she would shave if able but did not want to bother staff. CNAs, an LVN, the DON, and the Administrator all reported that facial grooming was typically offered on shower days and that staff were responsible for monitoring and ensuring residents’ grooming according to their preferences. Despite this and a facility policy on dressing and personal grooming, staff did not provide needed assistance with facial grooming, resulting in unmet ADL care needs for this resident.
The facility failed to follow its grievance policy by not documenting and tracking resident grievances related to staff care. The Social Worker, who had been the grievance coordinator for an extended period, reported that under the previous Administrator and DON she was instructed to verbally report care-related concerns to them instead of completing grievance forms, resulting in an almost empty grievance binder and no records prior to late in the year. The ADON stated that all care concerns should have been documented on grievance forms, and the current DON confirmed that the prior practice of only verbal reporting did not comply with the written grievance policy, which requires the grievance official to receive, track, investigate, and issue written decisions on grievances, including those involving staff behavior such as concerns about a CNA.
Surveyors found that two residents with indwelling catheters had drainage bags left uncovered and visible, despite physician orders and care plans requiring the bags to be kept in privacy covers while in bed or in a wheelchair. One resident with severe cognitive impairment and multiple medical conditions, including urinary system disorder and liver disease, was observed in bed with family present while her catheter bag lacked a privacy bag. Another cognitively impaired resident with neuromuscular bladder dysfunction and other comorbidities was observed asleep in bed with her catheter bag clipped to the bed and visible from the hallway without a privacy cover. Multiple CNAs, an LVN, the RN, the DON, and the Administrator all stated that catheter bags should always be in privacy bags to protect dignity and privacy, consistent with the facility’s resident rights policy.
The facility failed to maintain catheter drainage bags off the floor in accordance with its infection prevention and control program and residents’ care plans. Three residents with indwelling catheters, including individuals with chronic kidney disease, diabetes, liver disease, dementia, and a history of UTI, were observed with Foley bags either lying on the floor, on a fall mat, or with tubing on the floor, despite orders and policies requiring bags to be kept below bladder level, off the floor, and in privacy bags. Staff, including CNAs, LVNs, an RN, the DON, and the Administrator, acknowledged that catheter bags on the floor constituted an infection control concern and that facility policy required tubing and drainage bags to be kept off the floor, yet these practices were not consistently followed.
Staff failed to maintain resident dignity during meal assistance by not sitting at eye level while feeding and by not offering residents a choice regarding the use of clothing protectors. Several residents with cognitive and physical impairments were assisted with eating by staff who stood over them, and some were not asked if they wanted to wear a clothing protector before it was placed on them. These actions were contrary to facility policy and staff training, as confirmed by observations, interviews, and record reviews.
A Wound Care Nurse did not change gloves between contaminated and clean tasks while providing wound care to a resident with dementia and end stage renal disease, despite facility policy requiring glove changes to prevent cross-contamination. The nurse handled clean wound care supplies after assisting with repositioning and removing the dressing, and acknowledged the lapse. Facility leadership confirmed the expectation for glove changes and noted the nurse had not been trained on this aspect of infection control.
A resident with a seizure disorder and multiple complex conditions did not receive prescribed anticonvulsant medication for several doses, despite staff concerns and physician orders. The DON delayed intervention and failed to initiate protective measures or an immediate investigation, resulting in the resident experiencing a seizure. Staff responsible for medication administration falsely documented that the medication was given, and the incident was not promptly reported as required.
A resident with a seizure disorder did not receive multiple prescribed doses of Levetiracetam, an anticonvulsant, over two days. Medication Aides responsible for administration falsely documented that the medication was given, but later admitted it was not. The omission was discovered after the resident experienced a seizure, and staff confirmed the medication had not been administered as ordered.
A resident with a seizure disorder and multiple comorbidities was not administered prescribed anticonvulsant medication as ordered. An LVN reported suspicions to the DON, but the DON delayed reporting and investigation, instructing staff to gather more evidence instead of initiating immediate protective actions. The resident subsequently experienced a seizure, and interviews confirmed that the facility did not promptly investigate or implement measures to prevent further neglect.
A resident with cognitive impairments was unable to make private phone calls due to the facility's failure to provide a private area or alternative phone options. The resident used a corded phone in an open lobby, leading to conversations being overheard. Staff interviews revealed a lack of awareness and action to offer private phone use, despite the facility's policy on resident rights.
The facility failed to implement comprehensive care plans for two residents at risk of falls by not ensuring fall mats were in place while they were in bed. Despite care plans indicating the need for fall mats, observations revealed the mats were not used, and staff admitted to forgetting to position them. The DON confirmed the oversight, highlighting a lapse in following the facility's care planning policy.
A resident with cognitive impairments was subjected to verbal and physical abuse by a CNA during perineal care. The CNA was observed on video handling the resident roughly, leading to bruises. Despite the resident's dependency on staff for daily activities, the CNA did not seek assistance and made derogatory remarks. The incident was reported to the DON and local police, highlighting a failure to protect residents from abuse.
Two residents in an LTC facility did not receive proper perineal care, as CNAs failed to change gloves and perform hand hygiene, risking infection. One resident, with Down Syndrome and Dementia, was handled roughly and without proper hygiene measures. Another resident was not provided with adequate hand hygiene during care. These actions violated the facility's perineal care policy, which emphasizes infection prevention and resident dignity.
The facility did not post current nurse staffing information for two days, leaving outdated data from June 29 and June 10 visible. The DON, responsible for posting, had a family emergency and did not delegate the task, resulting in a lack of updated staffing data accessible to residents and visitors.
The facility failed to ensure the safe disposal of sharps, resulting in exposed razors and a syringe in a resident's room. This posed a risk to a cognitively impaired resident with wandering behavior, as well as to other residents and staff. Staff interviews confirmed that the proper procedure for disposing of sharps was not followed.
The facility failed to maintain an infection prevention and control program, as staff did not use gowns while providing care to two residents on enhanced barrier precautions, increasing the risk of infection transmission.
The facility failed to obtain informed consent before administering medications to three residents with severe cognitive impairments. Medications were given without proper documentation of consent, leading to residents receiving treatments without being fully informed.
The facility failed to ensure a resident's call light was within reach, despite the resident's severe cognitive impairment and fall risk. The call light was observed hanging on the wall, out of reach, and staff confirmed the oversight. The facility lacked specific policies addressing call light placement.
The facility failed to ensure that a resident's MDS assessment accurately reflected physical behaviors. The MDS did not document an incident where the resident kicked another resident, which was recorded in progress notes but overlooked during the assessment.
The facility failed to provide necessary hygiene and grooming services for two residents, one with severe cognitive impairment and another with moderate cognitive impairment. Staff did not offer alternative hygiene options or properly document refusals, and failed to address a resident's request for facial hair removal, leading to poor hygiene and discomfort.
A resident with a history of UTIs and other medical conditions had her catheter tubing improperly placed on the floor, increasing the risk of infection. Staff failed to adhere to care protocols, and the issue was confirmed through observations and interviews.
A CNA changed a resident's colostomy bag and wafer without proper training, leading to unsupervised and potentially improper care. The ADON and RN involved did not adequately supervise or stop the CNA, and facility documentation revealed a lack of training and clarity regarding CNA responsibilities for colostomy care.
The facility failed to ensure that medication cart #1 was locked when unattended, leaving it unlocked for approximately eight minutes while an LVN administered insulin. Additionally, discontinued medications were not locked in medication rooms. The DON confirmed that staff were reminded of the requirement to keep medication carts locked, but compliance was not achieved.
The facility failed to adhere to professional standards for food safety, including leaving seasonings and cheese unsealed, storing expired pudding, and allowing staff to wear inappropriate footwear. Dust buildup was also observed on a vent under a tea maker.
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 Provide Needed ADL Assistance With Facial Grooming
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for a resident who was unable to fully perform these tasks. The resident was an elderly female with age-related cognitive decline and polyosteoarthritis, and a Quarterly MDS showing a BIMS score of 09, indicating moderate cognitive impairment. Her care plan, revised on 03/13/2026, identified an ADL self-care performance deficit and included interventions for assistance with personal hygiene, including hair, shaving, and oral care as needed. On 03/30/2026 at 9:56 AM, the resident was observed with black hair on her upper lip and black and gray hair on her chin. She stated that she would shave herself if she could, but did not want to ask staff because she did not want to bother them. Staff interviews confirmed that grooming, including facial grooming, was generally performed on shower days, about two days per week, and that CNAs and nurses were responsible for monitoring and ensuring residents’ grooming. CNA A stated that facial grooming was done on shower days and that CNAs were to ask residents if they wanted facial hair shaved, acknowledging that long facial hair in female residents could affect self-esteem. LVN B similarly stated that residents were offered facial grooming on shower days and that nurses were responsible for ensuring residents were well groomed, noting that female residents with long facial hair could be emotionally affected or embarrassed. The DON and Administrator both reported that facial grooming should be done as needed and according to resident preference, and that all staff shared responsibility for ensuring residents were well groomed. Despite these stated responsibilities and the facility policy on dressing and personal grooming, the resident’s facial hair was not addressed, indicating that the facility did not implement the care plan interventions to assist with personal hygiene and grooming as required.
Failure to Document and Track Resident Grievances per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances and to follow its own grievance policy, including proper documentation and tracking of grievances. During an observation, the Social Worker provided the grievance binder, which contained documentation only back to December 2025, despite her having been the appointed grievance coordinator since October 2024. The facility’s written grievance policy, dated 11/2/2016, states that residents have the right to voice grievances regarding care and treatment, staff behavior, and other concerns, and that the grievance official must oversee the grievance process, receive and track grievances to their conclusion, lead investigations, and issue written grievance decisions. In interviews, the Social Worker stated she had no documented grievance forms from residents regarding care from staff prior to the recent period and explained that, under the previous DON and Administrator, she had been instructed not to complete grievance forms for grievances related to staff care. Instead, she was told to verbally report such concerns directly to the previous DON and Administrator, who indicated they would handle them, and she did not document these grievances despite recognizing that resident care concerns qualified as grievances that needed to be documented. She acknowledged that this practice was not in compliance with the facility’s grievance policy and that concerns such as those involving CNA A should have been documented in accordance with that policy. The ADON confirmed that residents could report care concerns to any staff member and that quality-of-care concerns reported to her should have been documented on a grievance form, adding that everything needed to be documented in the system and grievance binder. She stated she was not aware of the previous Administrator’s and DON’s instructions to the Social Worker not to document grievances related to staff care. The current DON observed that the grievance binder appeared empty, with the earliest grievances only dating back to December 2025, and stated that the prior practice of only verbally reporting concerns to the previous DON and Administrator was not aligned with the facility’s grievance policy. She noted that without adherence to the policy and proper documentation, grievances could be lost, the facility could be unaware if grievances were unresolved, and there would be no documentation to support resolution or to reference during investigations, including those related to CNA A’s behavior.
Uncovered Foley Bags Compromise Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure resident dignity by not keeping urinary catheter drainage bags covered with privacy bags as required by physician orders, care plans, and facility practice. For one resident, an older female with diagnoses including urinary system disorder, chronic Hepatitis C, hypokalemia, acute kidney disease, and cirrhosis, record review showed an indwelling suprapubic catheter and an order specifying that the Foley bag must be in a privacy bag while the resident is in bed or in a wheelchair. Her care plan also directed that the catheter bag and tubing be positioned below the level of the bladder and in a privacy bag. During an observation while the resident was in bed with a family member present, the catheter drainage bag was noted to be uncovered and without a privacy bag. A second resident, an older female with dysphagia, muscle wasting and atrophy, anemia, hyperlipidemia, dementia, hypertension, GERD, and neuromuscular dysfunction of the bladder, also had an indwelling catheter. Her orders required Foley catheter care every shift, including ensuring the Foley was secured on the thigh and the drainage bag was inside a privacy bag attached to the bed rail every shift. Her care plan similarly directed that the catheter bag and tubing be positioned below the level of the bladder and in a privacy bag. During observation, this resident was asleep in bed, non‑responsive to the investigator, and her catheter bag was clipped to the right side of the bed, visible from the hallway, with no privacy bag covering it. Multiple staff interviews confirmed that facility staff were trained that catheter bags should always be in privacy bags to maintain resident dignity and privacy. A CNA with 13 years of employment, another CNA, an LVN, the RN, the DON, and the Administrator each stated that catheter bags were expected to be covered with privacy bags and that failure to do so was a dignity or privacy issue. The facility’s Resident Rights policy stated that each resident must be treated with respect and dignity, including privacy and confidentiality, and that the facility must protect and promote residents’ rights. Despite these expectations, the observed uncovered catheter bags for the two residents demonstrated that the facility did not ensure residents’ right to a dignified existence and privacy as outlined in their orders, care plans, and facility policy.
Failure to Maintain Catheter Drainage Bags Off the Floor Under Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program related to the management of indwelling urinary catheter drainage bags for three residents. For one resident, an older female with diagnoses including disorder of the urinary system, chronic viral Hepatitis C, hypokalemia, acute kidney disease, and cirrhosis of the liver, surveyors reviewed records showing she had an indwelling suprapubic catheter. Her care plan and physician orders directed that the catheter bag and tubing be positioned below the level of the bladder, kept off the floor, and placed in a privacy bag. During an interview and observation while the resident was in bed with a family member present, the resident’s catheter bag was observed lying on the floor, contrary to the documented orders and care plan. A second resident, an older male with diagnoses including type 2 diabetes, thrombocytopenia, and benign prostatic hyperplasia with lower urinary tract symptoms, also had an indwelling catheter. His orders and care plan similarly required that the Foley bag be kept in a privacy bag while in bed or wheelchair, positioned below the bladder, and maintained off the floor with tubing checked for kinks. During observation, this resident was found asleep in bed with the catheter bag inside a blue privacy bag on the right side of the bed. The bag was not hooked to the bedrail and was lying sideways with the tubing on the floor, in direct conflict with the facility’s catheter care policy and the resident’s individualized care plan. A third resident, an older male with chronic kidney disease, conversion disorder with seizures, viral hepatitis C, dementia, type 2 diabetes, and a history of UTI, also had an indwelling catheter. His orders and care plan required that the Foley bag be in a privacy bag every shift, positioned below the bladder, and kept off the floor to prevent catheter-related trauma. During observation, this resident was in bed and became aggressive when the investigator attempted conversation. The catheter bag was found on the right side of the bed inside a blue privacy bag, not hooked to the bedrail, and sitting upright on a fall mat. Staff interviews, including with LVNs, CNAs, the RN, the DON, and the Administrator, confirmed that catheter bags on the floor or touching surfaces were considered an infection control concern and that facility policy required tubing and drainage bags to be kept off the floor. Despite this, the observed practices for these three residents did not comply with the facility’s catheter care and standard precautions policies, resulting in the cited infection control deficiency. Staff interviews further clarified the actions and inactions contributing to the deficiency. One LVN stated that due to the requirement to keep beds in the lowest position for fall risk residents, the catheter bags would always be touching the floor or fall mats, and initially believed this was acceptable. During the same interaction, the LVN was able to adjust two residents’ Foley bags so they were no longer touching the floor mat and were upright to prevent leakage, indicating that proper positioning was feasible but not consistently implemented. Multiple CNAs and an RN acknowledged that catheter bags should not be on the floor and identified this as an infection control issue. The DON and Administrator both stated that catheter bags were to be kept below the bladder, off the floor, and in privacy bags, and that bags on the floor represented an infection control problem, while lack of privacy bags was a dignity concern. Record review of the facility’s catheter care and standard precautions policies confirmed that tubing and drainage bags were to be kept off the floor and that appropriate infection control measures were required for each resident interaction. These observations and statements collectively demonstrate that the facility did not consistently implement its infection prevention and control program for residents with indwelling catheters.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat several residents with respect and dignity during meal assistance, as evidenced by staff not sitting at eye level while assisting with feeding and not offering residents a choice regarding the use of clothing protectors. Observations revealed that multiple staff members, including a student CNA and CNAs, assisted residents with eating while standing, rather than sitting at eye level as required by facility policy and staff training. This practice was observed with at least three residents who had varying degrees of cognitive impairment and required different levels of assistance with eating. Staff interviews confirmed that they were aware of the expectation to sit while assisting with feeding, but some staff cited physical limitations or personal preference as reasons for not following this protocol. Additionally, the facility failed to ensure that residents were asked if they wanted to wear a clothing protector before it was placed on them. One resident reported not being asked and feeling unable to refuse once the protector was already on. Staff interviews indicated that it was common practice for some staff to put clothing protectors on residents without asking, despite being trained to offer residents a choice. The facility's policy and staff training emphasized the importance of promoting resident dignity and self-determination by offering choices and engaging residents in their care. The residents involved had significant medical histories, including dementia, diabetes, impaired mobility, and cognitive communication deficits, which made them dependent on staff for assistance with eating and other activities of daily living. The failure to follow established protocols for meal assistance and resident choice was confirmed through direct observation, staff and resident interviews, and review of facility policies and care plans. These actions and inactions resulted in a failure to maintain an environment that promotes or enhances residents' quality of life and dignity.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care for a resident with significant medical needs, including unspecified dementia and end stage renal disease. During an observed wound care procedure, the Wound Care Nurse did not change gloves between contaminated and clean tasks. Specifically, after assisting with repositioning the resident and removing the dressing, the nurse continued to handle clean wound care supplies, such as Anasept and collagen, with the same gloves. The nurse acknowledged the lapse and stated she was nervous, but recognized that gloves should have been changed prior to touching clean supplies. The resident was unable to respond to questions due to severe cognitive impairment. Interviews with the DON and Administrator confirmed that facility policy requires gloves to be changed between dirty and clean tasks during wound care, and that the Wound Care Nurse had not received specific training on cross-contamination prevention. Review of facility policies further supported the expectation for hand hygiene and glove changes during wound care procedures. The failure to follow these protocols was directly observed and acknowledged by staff, and was not in accordance with the facility's established infection control policies.
Failure to Administer Anticonvulsant Medication and Protect Resident from Neglect
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder, dementia, intellectual disabilities, and other complex medical needs did not receive prescribed anticonvulsant medication (Levetiracetam) as ordered by the physician. The resident was non-verbal and required strict adherence to medication administration to prevent seizures. Despite a physician's order to increase the dosage due to previously low medication levels, the medication was not administered for four consecutive doses over a weekend. Medication Aides responsible for administering the medication failed to do so but documented in the electronic medication administration record that the medication had been given. The charge nurse reported concerns to the DON regarding the resident not receiving the anticonvulsant medication as ordered, based on low lab values. However, the DON did not immediately implement protective measures or initiate an investigation. Instead, the DON instructed the nurse to gather evidence by monitoring the medication bottle, delaying any intervention until after the weekend. During this period, the resident missed multiple doses of the critical medication, and no immediate steps were taken to ensure the resident's safety or to verify medication administration. As a result of the missed doses, the resident experienced a seizure, which was documented by nursing staff. The incident was not promptly reported to the facility administrator or to the state as required. Interviews with staff revealed a lack of immediate action and failure to follow facility policy regarding the reporting and investigation of neglect. The deficiency was identified as Immediate Jeopardy due to the failure to protect the resident from neglect and to ensure medications were administered as ordered.
Failure to Administer Anticonvulsant Medication as Ordered
Penalty
Summary
A significant medication error occurred when a resident with a history of seizure disorder, dementia, dysphagia, intellectual disabilities, Down Syndrome, and anxiety disorder did not receive prescribed doses of Levetiracetam, an anticonvulsant medication. The resident was ordered to receive Levetiracetam 100 mg/ml, 7.5 ml by mouth twice daily for seizures. However, the medication was not administered as ordered on four occasions over two consecutive days. Medication Aides responsible for administering the medication documented in the electronic medication administration record (eMAR) that the doses were given, but later admitted during interviews that the medication was not actually administered. The failure to administer the medication as ordered was discovered after the DON was alerted by an LVN who suspected the medication was not being given. The DON instructed the LVN to take pictures of the medication bottle to compare the amount before and after the weekend, which revealed no change in the medication volume, confirming the medication had not been administered. The resident subsequently experienced a seizure, which was documented by nursing staff, including observations of shaking extremities, eyes rolling back, jerking arms, decreased oxygen saturation, and unconsciousness. The physician was notified following the seizure event. Interviews with the involved Medication Aides revealed that one aide forgot to administer the medication after being distracted by another task, while the other aide did not remove the medication from the drawer and falsely documented administration. One of the aides had a prior history of similar documentation errors. The incident was recognized as neglect by staff and was reported to the facility's Abuse Coordinator and DON. The deficiency was identified as Immediate Jeopardy due to the failure to ensure the resident's drug regimen was free from significant medication errors, specifically the omission of critical anticonvulsant medication.
Failure to Investigate and Prevent Neglect Following Missed Medication Administration
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and that measures were taken to prevent further incidents while an investigation was in progress. Specifically, a non-verbal female resident with multiple diagnoses, including seizure disorder, dementia, and intellectual disabilities, was not administered her prescribed anticonvulsant medication (Levetiracetam) as ordered. The resident's care plan required strict adherence to medication administration and documentation of seizure activity, but there was a lapse in ensuring the medication was given as prescribed. On a specific date, an LVN reported to the DON a suspicion that a medication aide was not administering the resident's Keppra as ordered, based on a low medication level. The DON did not immediately report the allegation to the Administrator or initiate an investigation. Instead, the DON instructed the LVN to gather more evidence by monitoring the medication bottle and delayed any intervention until several days later, when audits of anticonvulsant medication administration were initiated. During this period, the resident experienced a seizure, which was observed and documented by the LVN, including a drop in oxygen saturation and loss of consciousness. Interviews revealed that the Administrator, who served as the Abuse Coordinator, was informed of the suspicion but did not recall being told what immediate actions would be taken to protect the resident. The facility did not immediately initiate an investigation or implement protective measures for the resident or others potentially at risk. The delay in reporting and investigating the allegation, as well as the lack of immediate interventions, constituted a failure to respond appropriately to an alleged violation of neglect.
Failure to Provide Private Telephone Access
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to a telephone and a private area to make calls without being overheard. The resident, who was admitted with diagnoses including schizoaffective disorder, anxiety, major depressive disorder, and dementia, expressed discomfort using the corded phone located in the open lobby area near the nursing station. This setup did not provide privacy, as conversations could be overheard by staff and others in the vicinity. Despite the resident's cognitive impairment, she was aware of the lack of privacy and expressed discomfort about the situation. Interviews with staff revealed that a portable phone, which could have been used for private calls, was lost, and no alternative private phone options were consistently offered to the resident. The Director of Nursing acknowledged the issue and noted that not all staff were aware of the need to offer a private phone option. The facility's policy on resident rights, which includes the right to private phone use, was not adhered to in this case, leading to a deficiency in respecting the resident's privacy rights.
Failure to Implement Fall Risk Interventions for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and time frames to meet their medical and nursing needs. Specifically, the facility did not adhere to the care plans for fall risk management by failing to ensure that fall mats were in place next to the beds of the residents while they were lying down. This oversight was observed during a survey, where the fall mats were found folded and not in use, contrary to the care plan requirements. Resident #1, a female with severe cognitive impairment and a high risk for falls, was observed without fall mats in place while lying in bed. Despite having a history of self-transferring and a care plan intervention that included fall mats, the staff failed to implement this safety measure. The Director of Nursing (DON) acknowledged the absence of the fall mat and stated it was the responsibility of the staff to ensure its placement. A Certified Nursing Assistant (CNA) admitted to forgetting to put the mat down after the resident had breakfast. Similarly, Resident #8, who had moderate cognitive impairment and required substantial assistance with mobility, was also found without fall mats in place. The DON confirmed that the resident was a fall risk and that the mats should have been in place as per the care plan. A Licensed Vocational Nurse (LVN) and a CNA both acknowledged the oversight, with the CNA admitting to forgetting to reposition the mats after attending to the resident. The facility's policy mandates that each resident's care plan should reflect interventions to meet their needs, which was not adhered to in these cases.
Abuse Incident During Perineal Care
Penalty
Summary
The facility failed to ensure that all residents were free from abuse, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident with Down Syndrome, dementia, and seizures. The incident occurred during perineal care, where the CNA was observed being verbally and physically abusive towards the resident. The CNA was seen on video aggressively handling the resident, including forcefully positioning her limbs and using excessive force while changing her brief. The resident was later found with multiple bruises, although she did not report any pain. The resident involved in the incident was a female with significant cognitive impairments, including dementia and Down Syndrome, and was dependent on staff for activities of daily living. The resident's care plan indicated that she required substantial assistance for mobility and was frequently incontinent. Despite these needs, the CNA did not seek assistance from other staff members and instead handled the resident roughly, which was captured on video by a family member's camera. The CNA involved in the incident had been employed at the facility for six years without prior complaints. However, during the incident, the CNA was heard making derogatory remarks towards the resident and failed to change gloves during the procedure, indicating a lack of adherence to proper care protocols. The facility's Director of Nursing (DON) and other staff members were notified of the incident, and the local police were involved after the bruises were discovered. The facility's policy on abuse and neglect clearly states that residents have the right to be free from abuse, which was not upheld in this case.
Deficient Perineal Care Practices
Penalty
Summary
The facility failed to ensure that two residents who were unable to perform activities of daily living received the necessary services to maintain good grooming and personal and oral hygiene. Specifically, the report highlights deficiencies in the provision of perineal care for two residents. CNA A did not adhere to professional standards while providing perineal care to Resident #2, who was frequently incontinent and dependent on staff for toileting and lower dressing. The video evidence showed that CNA A did not change gloves during the procedure, handled the resident roughly, and did not use wipes, which are essential for infection control. Resident #2, a female with Down Syndrome, Dementia, and Seizures, was admitted to the facility and required substantial assistance for bed mobility and toileting. The care plan indicated that Resident #2 was frequently incontinent and required one staff member for assistance with ADLs. The video recordings provided by the family member showed CNA A mishandling the resident, failing to change gloves, and not using wipes, which was confirmed by the DON and LVN B during interviews. These actions were not in line with the facility's perineal care policy, which emphasizes infection prevention and maintaining resident dignity. Similarly, CNA K failed to change gloves or perform hand hygiene while conducting perineal care for Resident #7. During an observation, CNA K was seen handling the resident's clothing and wheelchair without changing gloves, which could lead to contamination and infection. The facility's perineal care policy outlines the importance of hand hygiene and proper glove use to prevent infections and maintain cleanliness. Both CNAs' actions were inconsistent with the facility's standards and training, posing a risk of infection to the residents.
Failure to Post Current Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors for two specific days, June 30, 2024, and July 1, 2024. Observations on July 1, 2024, revealed that the staffing information posted was outdated, with the most recent data being from June 29, 2024. Further observations showed that information from as far back as June 10, 2024, was still displayed, indicating a lack of current staffing data. This deficiency was confirmed through interviews and record reviews, highlighting that the required information, including the facility name, current date, resident census, and total hours worked by nursing staff, was not maintained as per regulations. During an interview, the Director of Nursing (DON) acknowledged the oversight, explaining that she was responsible for posting the staffing information over the weekend of June 29-30, 2024. However, due to a family emergency, she did not fulfill this duty and failed to delegate the task to others. Consequently, the Assistant Directors of Nursing (ADONs) also did not post the necessary information on July 1, 2024. The DON admitted that the absence of this information could prevent staff members and family members from being informed about the current staffing situation at the facility.
Failure to Ensure Safe Disposal of Sharps
Penalty
Summary
The facility failed to ensure that the residents' environment remained free of accident hazards and that each resident received adequate supervision to prevent accidents. During observations, it was noted that the sharps container in a resident's room had disposable razors and a syringe exposed and reachable on top of the box. This posed a risk to the resident, who had a history of wandering and cognitive impairment, as well as to other residents and staff members who might come into contact with the exposed sharps. Interviews with staff confirmed that the procedure for disposing of sharps was not followed correctly, leading to the potential for injury and contamination. Resident #2, a male with multiple diagnoses including dementia, anxiety, and delusional disorders, was observed to have severely impaired cognitive status and required substantial assistance with daily activities. His care plan indicated a need for a safe environment and close supervision due to his tendency to wander and impaired safety awareness. Despite these precautions, the presence of exposed sharps in his room created a significant hazard, especially given his propensity to take items he finds. Interviews with the Licensed Vocational Nurse (LVN), Nursing Assistant (NA), and Director of Nursing (DON) revealed that the facility's policy required used sharps to be placed intact into sharps containers immediately after use. However, the staff admitted that the procedure was not followed, resulting in the exposed razors and syringe. The DON acknowledged the risk posed by the exposed sharps to both residents and staff, particularly in a facility where multiple residents exhibit wandering behaviors.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to potential cross-contamination and the spread of infection among residents. Specifically, two residents on enhanced barrier precautions did not receive the required protective measures from the staff. Resident #46, who has multiple diagnoses including cerebral infarction and type 2 diabetes mellitus, was observed receiving care from LVN E without the use of a gown, despite the resident being on enhanced barrier precautions. LVN E administered insulin and checked the resident's blood sugar without donning a gown, contrary to the facility's policy for residents on enhanced precautions. Similarly, Resident #74, who has diagnoses including cerebral infarction and COPD, was also on enhanced barrier precautions. RN F was observed administering medications via a PEG tube without wearing a gown. The resident, who has severely impaired cognition, was in close contact with RN F during the procedure, yet the required protective gown was not used. Both residents' care plans and physician orders clearly indicated the need for enhanced barrier precautions, including the use of gowns and gloves during high-contact activities. Interviews with the staff revealed a lack of understanding and adherence to the enhanced barrier precautions policy. LVN E admitted to being unsure about the necessity of gowning up for activities other than wound care, while the DON confirmed that all staff were trained monthly on infection control and PPE use. Despite the presence of signage and PPE carts outside the residents' rooms, the staff failed to comply with the facility's infection control policies, thereby increasing the risk of infection transmission.
Failure to Obtain Informed Consent for Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments. Specifically, the facility did not obtain informed consent from three residents before administering medications. Resident #29, who had severe cognitive impairment and multiple health conditions including anxiety, was given Lorazepam without consent from 10/8/23 to 10/13/23. The consent was only signed on 10/13/23, after the medication had already been administered for several days. Resident #46, who also had severe cognitive impairment and multiple health conditions including seizures, was administered Valproic Acid without any consent on file from 6/1/23 to 5/15/24. The Director of Nursing (DON) acknowledged the absence of consent and stated that the resident had been receiving the medication for nearly a year without proper documentation. Resident #90, who had severe cognitive impairment and multiple health conditions including depression, was given Fluoxetine without consent from 5/3/24 to 5/8/24. The consent was signed on 5/8/24, after the medication had already been administered. The DON admitted to challenges in the consenting process and stated that the charge nurses were responsible for obtaining consent prior to medication administration, but acknowledged occasional lapses in this process.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that Resident #1's call light was within reach, which is a reasonable accommodation of the resident's needs and preferences. Resident #1, a male with severe cognitive impairment and multiple diagnoses including dementia, muscle weakness, and a history of falls, was observed on 5/15/2024 with his call light hanging on the wall about three feet from his bed, out of his reach. This observation was confirmed by NA D, who acknowledged that the call light should always be within reach, especially given Resident #1's fall risk and history of falls. Further interviews revealed that the Director of Nursing (DON) also acknowledged the risk posed by the call light being out of reach, stating that Resident #1 would not be able to get the help he needed and could potentially fall if he tried to get up to reach the call light. The facility's policies and procedures were reviewed, and it was found that there were no specific policies addressing the placement of call lights. This deficiency could place residents at risk of not having their needs met and a decline in their quality of care and life.
Inaccurate MDS Assessment for Resident's Physical Behaviors
Penalty
Summary
The facility failed to ensure that a resident's MDS assessment accurately reflected the resident's behaviors. Specifically, the MDS for a male resident with a history of cerebral infarction and major depressive disorder did not document an incident where the resident exhibited physical behaviors by kicking another resident, which resulted in bruises. This incident was recorded in the resident's progress notes but was overlooked during the MDS assessment's seven-day look-back period, leading to an inaccurate assessment. During interviews, the MDS Coordinator admitted to overlooking the incident and acknowledged that the MDS did not accurately reflect the resident's behavior. The Director of Nursing (DON) confirmed that the expectation was for MDS assessments to capture all pertinent information accurately. The facility's policy on documentation emphasizes the importance of maintaining complete and accurate records, which was not adhered to in this case.
Failure to Provide Necessary Hygiene and Grooming Services
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and hygiene for two residents who were unable to carry out activities of daily living. Resident #45, a male with severe cognitive impairment and diagnosed with unspecified dementia, was observed to be unshaved, wearing the same clothes from the previous day, and emitting a foul odor. Despite his resistance to care, staff did not offer alternative hygiene options such as bed baths, and there was a lack of proper documentation regarding his refusal to shower. Interviews with staff revealed inconsistencies in the approach to his care and a failure to document refusals and alternative care measures properly. Resident #40, a female with moderate cognitive impairment and diagnosed with diabetes, expressed a desire to have her facial hair removed but was not assisted with this grooming need. Despite her vocal requests, staff failed to address her concern, leaving her with facial hair that made her feel uncomfortable. Observations and interviews indicated that staff were aware of her preference but did not follow through with the necessary grooming assistance. The deficient practices in both cases placed the residents at risk of poor hygiene and a decline in self-esteem. The facility's failure to document refusals and provide alternative care measures, as well as the lack of attention to individualized grooming needs, contributed to the deficiencies observed by the surveyors.
Failure to Prevent Urinary Tract Infections Due to Improper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with urinary incontinence received appropriate treatment and services to prevent urinary tract infections. Specifically, the resident's indwelling catheter tubing was observed laying on the floor, and the subpubic catheter was not properly secured. This failure was noted during observations and interviews with staff, where it was revealed that the catheter bag was inappropriately placed on the floor, covered only by a blue privacy bag. The CNA incorrectly believed that the privacy bag was sufficient to prevent contamination, while the RN later acknowledged the risk of infection and properly secured the catheter bag off the floor. The resident involved was an elderly woman with a history of urinary tract infections, Alzheimer's, dementia, diabetes, and gross hematuria. Her care plan specified that the catheter tubing should remain off the floor and that staff should monitor for signs of urinary infection. Despite these instructions, the catheter bag was found on the floor during multiple observations, and staff interviews confirmed a lack of adherence to proper catheter care protocols. The Director of Nursing also confirmed that the catheter bag should not be on the floor due to the increased risk of infection and emphasized the responsibility of CNAs and nurses to ensure proper catheter placement at every shift change.
Failure to Ensure CNA Competency in Colostomy Care
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in skills and techniques necessary to care for residents' needs, as evidenced by an incident involving a resident with a colostomy. A CNA changed the resident's colostomy bag and wafer without having been trained on the procedure. The CNA noticed the colostomy bag was too full and decided to change it herself, using alcohol prep wipes to cleanse the area around the stoma. She was unaware of the proper steps, such as applying sure-prep, and proceeded without notifying a nurse or having a nurse present during the procedure. The Assistant Director of Nursing (ADON) and a Registered Nurse (RN) were involved but did not adequately supervise or stop the CNA from continuing the procedure. The ADON initially assisted by cutting the wafer to size but did not ensure the CNA was properly trained or that a nurse was present to oversee the procedure. The RN and ADON both left the room, allowing the CNA to complete the colostomy care unsupervised. Interviews with the RN, ADON, and Director of Nursing (DON) revealed confusion and lack of clarity regarding the roles and responsibilities of CNAs in performing colostomy care. The facility's documentation and policies did not indicate that CNAs were trained on colostomy care. The DON confirmed that only nurses were expected to change colostomy bags and wafers, and the CNA should have informed a nurse when the colostomy bag needed changing. The Administrator was unaware of the specific policies regarding CNA responsibilities for colostomy care and indicated he would look into the issue. The facility's coaching forms and proficiency audits further highlighted the lack of training and clarity in the roles of CNAs regarding colostomy care.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls and that only authorized personnel had access to medications. Specifically, medication cart #1 was left unattended and unlocked by an LVN, who walked away from the cart to administer insulin. The cart remained unattended and unlocked for approximately eight minutes before the LVN noticed and locked it. During an interview, the LVN acknowledged that she must have overlooked locking the cart and was aware of the requirement to keep medication carts locked when unattended. Additionally, the facility failed to ensure that discontinued medications were locked in medication rooms. The Director of Nursing (DON) confirmed that the expectation was for all medication carts to be locked when unattended and mentioned that there had been a recent in-service training and a reminder sent out to staff about this requirement. Despite these measures, the staff did not comply with the policy. The facility's policy, dated 2003, clearly states that medication carts should be locked when not in use or under direct supervision and must be secured.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that various seasonings such as Cream of Tartar, Salt, and Dill weed were left opened, and a bag of cheese in the walk-in refrigerator was not sealed correctly. Additionally, expired instant pudding was found in the dry storage room. The facility also had a vent with dust buildup located under a tea maker, which was not in use but still required regular cleaning. Dietary staff were observed wearing inappropriate footwear, specifically Crocs with holes, which is against the facility's dress code policy. Interviews with dietary staff and the dietary manager confirmed these observations. The dietary manager acknowledged that the seasonings should not have been left open and that the expired pudding needed to be discarded. He also admitted that the bag of cheese should have been sealed properly to prevent contamination. Despite the facility's dress code policy prohibiting Crocs with holes, the dietary manager allowed their use, stating that they were non-slip and comfortable, although he recognized the potential risk of burns from dropped items.
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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