San Rafael Nursing And Rehabiliation
Inspection history, citations, penalties and survey trends for this long-term care facility in Corpus Chrisit, Texas.
- Location
- 3050 Sunnybrook Rd, Corpus Chrisit, Texas 78415
- CMS Provider Number
- 675717
- Inspections on file
- 56
- Latest survey
- December 1, 2025
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at San Rafael Nursing And Rehabiliation during CMS and state inspections, most recent first.
The facility did not ensure that comprehensive care plans were timely developed and accurately updated for two residents. One resident's care plan failed to reflect a change in anti-anxiety medication frequency, while another resident's care plan did not include interventions for antihypertensive medication use. Facility staff confirmed that care plans should have been updated to match current physician orders and resident needs, as required by facility policy.
The facility did not ensure the DON refrained from working as a charge nurse during periods when the average daily census exceeded 60. The DON filled in as a charge nurse on multiple occasions when the facility was short-staffed, which was confirmed by staff interviews and schedule reviews. The facility lacked a policy regarding this practice.
Two residents with hypertension did not receive PRN Clonidine as ordered when their blood pressure readings met the parameters for administration. Staff interviews revealed lapses in following physician orders and inconsistent documentation of blood pressure readings and medication administration, resulting in significant medication errors.
Three residents with complex medical needs did not have their vital signs and blood pressure readings accurately or consistently documented in their medical records. Staff interviews revealed that previous readings were sometimes copied forward or not updated, and there was no consistent audit process in place. The facility's documentation policy requires complete and accurate records, but this was not followed, potentially impacting resident care.
A resident with severe cognitive impairment and a physician-ordered pureed diet was given a whole hot dog instead of the required pureed meal. The tray was not checked by a nurse before being served, leading to a choking incident that resulted in an anoxic brain injury. Staff interviews and records confirmed a mix-up in the kitchen and failure to follow verification procedures for meal trays.
A resident with multiple complex diagnoses was readmitted with a Coban wrap on his arm, but an LVN failed to perform a thorough head-to-toe assessment, including checking under the dressing, as required by the care plan and facility protocol. The dressing remained in place for several days without assessment, despite the resident's care plan noting a skin integrity issue at the site. The deficiency was confirmed by interviews and record review, with the DON acknowledging the assessment should have been completed.
A wound care treatment cart containing various medications and wound care supplies was found unlocked and unattended in a hallway, with staff unable to identify who last used it. Facility policy requires all such carts to be locked and accessible only to authorized personnel, but this cart was left unsecured, making its contents accessible to unauthorized individuals.
A nurse failed to document a bandage on a resident's forearm upon readmission, and another nurse did not provide detailed documentation of a skin irregularity during assessment. The resident, who had multiple diagnoses and required assistance with ADLs, had a care plan for a skin injury, but records lacked detailed observations and measurements as required by facility protocol. Staff acknowledged the omissions, and the DON confirmed that all findings should have been documented in detail.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report highlights insufficient safety measures and lack of proper oversight, but does not specify individual residents or detailed events.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as evidenced by surveyor findings that care was not consistent with the established care plan.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Surveyors found multiple failures in food service safety, including missing freezer thermometers, unclean kitchen equipment, improper utensil and pan condition, and inadequate water temperatures for sanitation. Food storage was deficient, with unlabeled and undated items, personal belongings stored with food, and improper stacking in refrigerators. Staff did not consistently follow hygiene protocols, and pest control issues were observed.
The facility did not maintain effective pest control in the kitchen, as evidenced by repeated sightings and staff observations of roaches in the ice machine, under the oven, and in storage areas. Despite weekly pest control services and a process for logging pest sightings, the issue persisted over several months, with staff interviews and record reviews confirming ongoing problems.
Nursing staff failed to consistently check or document blood pressure readings before administering antihypertensive and vasopressor medications to two residents, resulting in medications being given or withheld without following physician-ordered parameters. Staff sometimes used previous readings or administered medications when blood pressure was outside prescribed limits, despite facility policy and leadership expectations for proper monitoring and documentation.
A nurse failed to sanitize a blood pressure cuff between uses on multiple residents with complex medical conditions, and the facility did not post required Enhanced Barrier Precaution signage outside the rooms of two residents with wounds and indwelling catheters. Staff interviews revealed inconsistent infection control practices and uncertainty about which residents required special precautions due to missing signage.
A facility failed to include oxygen therapy in a resident's care plan, despite physician orders for oxygen to manage COPD. The resident's care plan lacked necessary details about oxygen therapy, which was confirmed by staff interviews. The MDS nurse and IDT team are responsible for updating care plans, but the omission was acknowledged, highlighting the importance of comprehensive care plans for resident care.
A resident with a history of falls and impaired mental status was found without a required floor mat on one side of her bed, contrary to physician orders and the care plan. Staff interviews confirmed responsibility for ensuring mats were in place, and the facility's fall prevention policy was not followed, resulting in a deficiency related to accident hazard prevention.
A resident with COPD and hypoxia was observed receiving oxygen at a higher flow rate than ordered, with the concentrator set at 3 liters per minute instead of the prescribed 2 liters. Staff interviews revealed a lack of awareness and verification of the correct oxygen setting, and the resident did not adjust the settings herself. Facility policy required adherence to physician orders for oxygen administration, but this was not followed.
Surveyors found that expired swab kits, a glucagon pen, a urine-vaginal-STI kit, and an enteral feeding tube de-clogger were not discarded from two medication rooms. The ADON confirmed the expired items had lost sterility and could impact resident care, and acknowledged oversight in removing these items after a change in lab companies.
The facility did not ensure the RD attended weekly weight meetings or provided required training and oversight, as confirmed by interviews and record review. The RD primarily attended monthly meetings, had limited direct resident interaction, and did not participate in staff in-services, contrary to the facility's agreement for consultant dietician services.
A resident with hypertension and other chronic conditions did not have blood pressure consistently checked or accurately documented before receiving antihypertensive medication, as required by physician orders. Nursing staff often recorded the same blood pressure readings on multiple days, sometimes when the resident was not present, and administered medication without proper assessment, contrary to facility policy and professional standards.
The facility did not maintain a safe and sanitary kitchen environment, with water dripping from an electrical conduit box, lighting fixture, and AC return, as well as visible water damage to sheetrock. Maintenance staff reported ongoing condensation issues, and the administrator identified a water heater problem that led to the use of paper dishes due to insufficient hot water for sanitizing dishware.
The facility failed to accurately document the administration of narcotic medications for three residents, leading to potential medication errors. A resident with severe cognitive impairment and two others with pain management needs received medications that were not properly recorded in the eMAR. Staff interviews revealed that documentation lapses were due to being busy, which could result in medication errors.
A facility failed to protect two residents from abuse and neglect, resulting in an altercation where one resident with severe cognitive impairment was pushed by another resident with a history of aggression, leading to a head injury. Despite existing interventions and staff awareness of the residents' conditions, the measures were insufficient to prevent the incident.
A resident's controlled medications, lorazepam and tramadol, were misappropriated during a transfer between halls in the facility. The medications were placed in a purple bag without proper documentation or verification, leading to the loss of 7 lorazepam tablets and 19 tramadol tablets. Staff interviews revealed inconsistencies in handling and documentation, and an investigation led to the termination of an LVN.
A resident with multiple diagnoses, including cerebral palsy and Parkinson's, fell from her bed when a CNA provided care without the required two-person assistance, as outlined in her care plan. The resident, dependent on staff for all ADLs, sustained injuries and was taken to the hospital. The incident revealed a failure to adhere to the facility's care protocols, resulting in the resident's fall and injury.
A medication room door on Hall 300 was left open and unlocked for five minutes while an LVN assisted a resident, contrary to facility policy requiring all medication storage areas to be secured. Although the refrigerator and discontinued medication tub were locked, the room itself was not, posing a potential risk.
A resident with a history of stroke and cognitive impairment was left in her room without access to a call light, contrary to her care plan which emphasized the need for call light accessibility due to fall risk. LVN B, who was new, left the resident unattended while addressing another patient's critical lab result. The facility acknowledged the oversight and conducted staff training on call light accessibility.
The facility's kitchen ventilation system was found to be dripping condensation, creating a slipping hazard and potential for cross-contamination. The Kitchen Manager and Maintenance Director were unaware of the issue, and no maintenance work orders were recorded for the problem. The Administrator acknowledged the slipping hazard but downplayed cross-contamination risks. The kitchen serves all residents except one on NPO status with a feeding tube.
A resident with hemiplegia experienced an assisted fall in the shower room, but the incident was not documented in her clinical records. Staff interviews revealed that the fall was not properly reported or documented, and the DON and Administrator were unaware of the incident until surveyor intervention. The facility's policy on accidents and incidents was not followed, as required notifications and documentation were not completed.
The facility failed to maintain a safe and comfortable environment, with significant water damage, exposed electrical cords, and inadequate maintenance of resident rooms and smoking areas. Observations revealed persistent issues despite closed work orders, and interviews with residents and staff highlighted concerns about the facility's condition.
Failure to Timely Update and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans in a timely and accurate manner for two residents, as required by policy. For one resident with Generalized Anxiety Disorder and Schizoaffective Disorder, the care plan was not updated to reflect a change in the administration frequency of an anti-anxiety medication, clonazepam, from twice daily to three times daily. Despite the physician's order being revised, the care plan continued to list the outdated dosing schedule. Interviews with the ADON, MDS nurse, and DON confirmed that the care plan should have been updated to reflect the current medication order, and that the MDS nurse was responsible for ensuring the care plan's accuracy. Another resident with diagnoses including heart disease, hypertension, and type two diabetes was not care planned for the use of antihypertensive medication, specifically Lisinopril, which had been ordered for hypertension management. The resident's care plan did not reflect the use of this medication, nor did it include interventions related to antihypertensive therapy, despite the resident's active diagnosis and ongoing treatment. The MDS nurse and RMDS both acknowledged that the care plan should have included this information and could not explain why it was omitted. Facility policy requires that comprehensive, person-centered care plans be developed and implemented for each resident, incorporating measurable objectives, timetables, and reflecting current standards of practice. The policy also states that care plans must be revised as residents' conditions or treatments change. In both cases, the failure to update and implement care plans as required resulted in care plans that did not accurately reflect the residents' current medical needs and treatments.
DON Served as Charge Nurse During High Census Periods
Penalty
Summary
The facility failed to ensure that the Director of Nursing (DON) did not serve as a charge nurse when the average daily occupancy was 60 or higher, as required. Record reviews showed that the DON was scheduled and worked as a charge nurse on four separate occasions over a two-month period, specifically on shifts in both the 100 and 300 halls. During these shifts, the facility's census ranged from 116 to 121 residents. Interviews with the Assistant Director of Nursing (ADON), the Administrator (ADM), and the DON confirmed that the DON filled in as a charge nurse when the facility was short-staffed, and that this was not a pre-scheduled assignment but rather a last-resort measure when no other nurse was available. The DON acknowledged that while working as a floor nurse, he was unable to perform all of his DON responsibilities. The ADM and ADON both stated that the DON was only called upon to serve as a charge nurse when absolutely necessary and not as part of the regular schedule. The facility did not have a policy addressing the DON working as a charge nurse. No specific residents or patient conditions were mentioned in relation to the deficiency.
Failure to Administer PRN Antihypertensive Medication as Ordered
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of Clonidine, an antihypertensive medication. For one resident, a female with a diagnosis of essential primary hypertension and an intact cognitive status, the physician's order specified that Clonidine 0.1 mg should be administered by mouth every 8 hours as needed for a systolic blood pressure greater than 170 or a diastolic greater than 100. On a specific date, her blood pressure was recorded as 172/103, but the as-needed Clonidine was not administered. The nurse responsible did not recall the order or the elevated blood pressure, and could not provide a reason for not administering the medication, suggesting possible distraction or documentation error. The resident did not recall experiencing symptoms of high blood pressure at that time. A second resident, a male with diagnoses including acute chronic kidney failure, hypertension, congestive heart failure, and type 2 diabetes, also had a physician's order for Clonidine 0.1 mg by mouth every 6 hours as needed for a systolic greater than 160 or diastolic greater than 100. Blood pressure logs showed two readings of 164/66, but the medication was not administered on those days, and the medication administration record reflected that Clonidine was not given at all during the month. Interviews with staff revealed inconsistencies in documentation practices, with one LVN admitting to sometimes not updating or recording blood pressures before medication administration, and a medication aide stating she always took and documented blood pressures but could not explain the missing documentation. The facility's policy required medications to be administered as prescribed and documented on the medication administration record. However, interviews with nursing leadership confirmed that there was no current process for auditing blood pressure documentation, and that staff should have rechecked elevated blood pressures and administered PRN antihypertensive medications as ordered. The lack of adherence to physician orders and documentation requirements led to significant medication errors for both residents.
Failure to Accurately Document Vital Signs and Blood Pressure in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for three residents, specifically regarding the documentation of vital signs and blood pressure readings. For one resident with multiple chronic conditions, including end stage renal disease and hypertension, the vital signs were not accurately documented in the Medication Administration Record (MAR) on a specific date, with identical readings entered for both morning and evening despite the resident being hospitalized part of that day. For another resident with chronic kidney disease and dependence on dialysis, blood pressure readings were inconsistently documented in both the blood pressure log and the MAR throughout the month, with several instances where readings were missing or not recorded at the required times for medication administration. A third resident, also with significant cardiac and renal diagnoses, had blood pressure readings that were either duplicated or not accurately entered in the records. Interviews with nursing staff revealed that sometimes previous blood pressure values would automatically populate in the electronic record, and staff would not always update them with current readings. Some staff admitted to not always recording the blood pressure after taking it, and there was no consistent process for auditing the accuracy of these entries. Staff also indicated uncertainty about the timing and content of in-service training related to medication administration and documentation. The facility's own documentation policy requires that all services, including medication administration and vital sign monitoring, be objectively, completely, and accurately recorded in the resident's medical record. The lack of accurate documentation could affect the care and treatment of residents, as the records did not reliably reflect the assessments and interventions performed. The deficiency was identified through record review and staff interviews, which confirmed that the required documentation was not consistently or accurately maintained for the residents involved.
Failure to Provide Prescribed Pureed Diet Results in Choking Incident
Penalty
Summary
A deficiency occurred when a resident who required a pureed diet due to severe cognitive impairment and multiple medical conditions was provided with a whole hot dog, a regular texture food item, instead of the prescribed pureed meal. The resident's medical records indicated a need for a mechanically altered diet with pureed texture and nectar consistency fluids, as ordered by the physician and documented in the care plan. Despite these clear dietary requirements, the resident received a tray containing a whole hot dog, which was not checked by a nurse before being delivered to the resident's room. The incident took place when a CNA delivered the food tray to the resident and assisted with the meal. The CNA's statement revealed that the resident immediately grabbed the hot dog and began eating it, leading to a choking episode. The CNA attempted to intervene, but the resident began to show signs of distress, prompting the CNA to call for help. The ADON responded, performed the Heimlich maneuver, and recovered pieces of regular bread and meat from the resident's mouth. Despite these efforts, the resident became unconscious and required CPR before being transferred to the hospital, where an anoxic brain injury was diagnosed. Interviews with facility staff, including the dietary aide, kitchen manager, DON, and Administrator, confirmed that the resident was given the incorrect food texture due to a mix-up in the kitchen and a failure to follow established procedures for verifying meal trays. The dietary aide and kitchen manager acknowledged that the resident's tray should have contained pureed food, and the DON and Administrator confirmed that staff did not adhere to the policy requiring nurse verification of trays before service. The investigation determined that the kitchen sent out the wrong tray, and staff failed to check the tray against the resident's dietary orders before it was served.
Failure to Complete Thorough Skin Assessment on Readmission
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to complete a thorough and accurate head-to-toe assessment for a male resident with multiple diagnoses, including cerebral infarction, muscle wasting, intellectual disabilities, hemiplegia, and hemiparesis, upon his readmission to the facility. The resident had a Coban wrap on his right arm, and the care plan specifically addressed an actual impairment to skin integrity at the right antecubital fossa related to the Coban wrap. Despite this, the LVN did not assess what was under the dressing/bandage during the initial assessment, and there was no documentation or mention of the resident's arm in the progress notes for several days following readmission. The resident was noted to have a dressing on his arm for approximately eight days without any clinical staff member assessing underneath it. The LVN reported that she noticed the dressing upon the resident's return but did not remove it or insist on assessing the underlying skin, citing the resident's resistance to care. The LVN acknowledged in hindsight that she should have advocated more strongly to assess under the dressing, as this is part of her professional responsibilities and necessary to ensure there were no negative outcomes such as loss of circulation or skin breakdown. The resident did not express or exhibit any signs or symptoms of distress during this period, and when interviewed, he recalled the incident but had no current concerns. An external advocate and the Director of Nursing (DON) both confirmed that the dressing remained in place for several days and that a thorough assessment should have been completed upon readmission. The facility's protocols and clinical guidelines require examination of the skin under all dressings for new admissions and readmissions, but this was not followed in this instance. The failure to assess under the Coban wrap could have compromised the resident's skin integrity, as noted in the report.
Unlocked Wound Care Cart with Medications and Supplies
Penalty
Summary
A wound care treatment cart was observed unlocked in front of the 100 hall nursing station, containing various drugs and biologicals such as betadine solution, hydrogen peroxide, triple antibiotic ointment, nystatin cream, diclofenac sodium gel, iodoform packing strips, lidocaine cream, and assorted bandages. The cart was not assigned to any staff member and staff interviewed were unsure who last used it. Facility policy requires all carts, including wound care carts, to be locked when not in use, and only authorized personnel are permitted access to drugs and biologicals. Interviews with an LVN, the DON, and the Administrator confirmed that the cart should have been locked and that leaving it unsecured was against facility policy and procedure. The facility's medication policy specifies that all drugs and biologicals must be stored in locked compartments and only accessible to authorized staff. The unlocked cart was accessible to anyone in the area, and the staff acknowledged that residents could potentially access and ingest or use the items inside.
Incomplete Documentation of Skin Assessment Findings
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was reviewed for total body skin assessment documentation. Upon readmission, a nurse did not document the presence of a bandage on the resident's forearm/elbow area, and later, another nurse failed to provide detailed documentation of a skin irregularity, including measurements and descriptive details, when assessing the resident's right arm. Both nurses acknowledged during interviews that they did not document their observations, with one stating she did not think it warranted documentation at the time, and the other admitting she did not think to include details in her note. The resident involved was an older male with multiple diagnoses, including cerebral infarction, muscle wasting, intellectual disabilities, hemiplegia, and hemiparesis. He had intact cognition and required assistance with most activities of daily living. The care plan indicated an actual impairment to skin integrity on the right antecubital fossa related to a Coban wrap, with interventions to monitor and document the injury. However, the medical record review showed that the resident was not coded for a major skin irregularity or wound, and the skin observation tool only noted redness without further detail. Interviews with staff and review of facility protocols confirmed that the expectation was to document all observational findings with detail, including measurements, description, and other relevant characteristics. The Director of Nursing stated that the nurses should have documented their findings as part of standard practice to ensure resident safety and proper monitoring of skin conditions. The lack of documentation was acknowledged by the staff involved, but it was noted that there were no negative outcomes for the resident as a result of these omissions.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential accidents. Specific actions or inactions leading to this deficiency were not detailed in the report, nor were any particular residents or incidents described.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the established care plan or the expressed wishes and clinical needs of the resident involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency is based on the observation that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting procedures were not followed as mandated. The report specifically notes the lack of timely communication and documentation to the appropriate authorities regarding both the suspicion and the outcome of the internal investigation.
Widespread Food Service Sanitation and Storage Failures
Penalty
Summary
Surveyors identified multiple failures in the facility's food service operations, including improper storage, preparation, distribution, and sanitation of food. Observations revealed that internal thermometers were missing from two freezers, and the kitchen contained unclean equipment such as a microwave with baked-on residue, dirty cups, and an ice machine with a removable brownish substance. Several kitchen utensils were found to be in poor condition, including a wooden spatula with splinters and a rubber spatula with missing pieces. Dented holding pans were in use and stored on clean racks, and the shelf above the stove had a flaking, rust-like substance. Additionally, the kitchen's dishwashing machine, 3-compartment sink, sanitizer sink, and hand washing sink were all operating below the required water temperature for proper sanitation. Food storage practices were also deficient. Boxes of food in the walk-in refrigerator were stacked too close to the ceiling, and containers of food in the refrigerator were not consistently labeled or dated. Personal items such as purses, backpacks, hoodies, and water bottles were stored on shelves with dry storage items and canned goods, contrary to facility policy. In the resident nutrition refrigerators located in two medication rooms, surveyors found unlabeled and undated food items, including store-bought sandwiches and restaurant takeout. The facility also failed to keep the side doors of dumpsters closed, as required by policy. Staff practices contributed to the deficiencies. Male staff members with beards and mustaches were observed wearing beard guards incorrectly, exposing facial hair, and one staff member failed to wash his hands after touching his phone and beard guard before returning to food preparation. Interviews with dietary staff confirmed awareness of policies regarding personal item storage and hand hygiene, but these policies were not consistently followed. The cleaning schedule was not properly maintained or posted, and pest control issues were noted, including the presence of roaches in the ice machine. These findings were corroborated by record reviews of facility policies, cleaning schedules, and staff competency checklists.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain effective pest control in the kitchen, as evidenced by multiple observations of roaches in various areas, including the upper mechanical part of the ice machine, under the oven, and in the hallway under dirty tray carts. Staff interviews confirmed ongoing issues with roaches, with one staff member reporting a roach falling from an AC return in her office and another acknowledging persistent problems under the stove. Pest control services were reportedly provided weekly, but staff were not consistently aware of pest sighting logs or the process for tracking pest activity. Invoices and service reports for pest control visits outside of regular schedules were not readily available for review. Record reviews of pest sighting logs from both the 100 and 200 halls documented repeated sightings of roaches and mice in the kitchen and related areas over several months. These logs indicated that pest activity was a recurring issue, with specific dates noting the presence of roaches in the kitchen, dry storage, dietary office, and other locations. Despite regular pest control treatments and a process for logging sightings, the facility did not effectively address or eliminate the pest problem in the kitchen, resulting in continued exposure to pests.
Failure to Ensure Accurate Blood Pressure Monitoring and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents who required blood pressure monitoring prior to administration of their antihypertensive and vasopressor medications. Nursing staff did not consistently check or document blood pressure readings before administering these medications, as required by physician orders that included specific hold parameters. In multiple instances, staff documented the same blood pressure readings across several days or used previous readings instead of obtaining current measurements, and in some cases, administered medications when the residents' blood pressure was outside the prescribed parameters. One resident, a male with a history of hypertension, hyperlipidemia, peripheral vascular disease, and type 2 diabetes, had a physician order for Lisinopril with instructions to hold the medication if blood pressure was below 110/60. Review of records showed that on several occasions, nursing staff either failed to check the resident's blood pressure or documented previous readings, yet still administered the medication. This pattern was observed over multiple days, with staff sometimes documenting the same blood pressure value for consecutive days and not performing the required assessment prior to medication administration. Another resident, a male with diagnoses including congestive heart failure, fluid overload, myocardial infarction, hypotension, and kidney disease, had orders for both a blood pressure decreasing medication (Metoprolol) and a blood pressure increasing medication (Midodrine), each with specific hold parameters. Nursing staff frequently failed to check or document current blood pressure and pulse readings before administering or withholding these medications. There were also instances where medications were administered despite the resident's blood pressure being outside the ordered parameters. Interviews with nursing staff and facility leadership confirmed that the expectation was to check and document vital signs before administering such medications, and that these procedures were not consistently followed.
Failure to Sanitize Equipment and Post Enhanced Barrier Precaution Signage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a medication pass, an LVN used a blood pressure cuff on several residents consecutively without sanitizing it between uses. The LVN admitted to forgetting to clean the cuff because the sanitizing wipes were left at the nurse's station. This practice was observed with five residents, each of whom had medical conditions such as hypertension, sepsis, meningitis, heart failure, and diabetes, and required regular blood pressure and pulse monitoring as part of their medication administration. Interviews with other nursing staff confirmed that the expectation was to clean reusable equipment between residents, but there was inconsistency in recalling the timing and content of infection control in-services. Additionally, the facility did not post Enhanced Barrier Precaution (EBP) signs outside the rooms of two residents who had orders for EBP due to conditions such as wounds and indwelling catheters. Observations revealed that there were no EBP signs on the doors or walls outside these residents' rooms, and staff interviews indicated uncertainty about which residents required EBP without proper signage. Some staff noted that while PPE carts were present, the absence of clear signage made it difficult to identify the specific type of precautions needed before entering the rooms. The facility's own policies and CDC guidelines require that reusable equipment be sanitized between residents and that clear signage be posted outside rooms for residents on EBP, indicating the required PPE and high-contact care activities necessitating gown and glove use. The lack of adherence to these protocols was confirmed through staff interviews and record reviews, which showed that while some infection control training had occurred, there was a lack of consistent implementation and communication regarding infection control measures and EBP signage.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with COPD, which included necessary oxygen therapy. During an observation, it was noted that the resident did not have any oxygen equipment in their room, despite having physician orders for oxygen therapy to maintain adequate oxygen saturation levels. The resident's care plan lacked any mention of oxygen therapy, including diagnosis, status, orders, parameters, or equipment, which are essential for addressing the resident's medical needs. Interviews with facility staff, including an LVN, MDS Nurse, DON, and ADON, revealed that care plans are typically updated by the MDS nurse and the IDT team. However, the MDS nurse acknowledged the absence of the oxygen care plan and its importance in ensuring residents receive appropriate care. The DON and ADON also confirmed that oxygen therapy should have been included in the care plan, emphasizing that care plans are crucial for guiding nursing staff in providing necessary care and treatment to residents.
Failure to Maintain Required Fall Prevention Devices at Bedside
Penalty
Summary
The facility failed to ensure that the environment for a resident at risk for falls was kept free from accident hazards and that required assistive devices were in place to prevent accidents. Specifically, a resident with a history of falls, impaired mental status, and diagnoses including benign paroxysmal vertigo and cerebrovascular accident, was observed without a floor mat positioned on the right side of her bed as ordered by her physician. The mat was found leaning against the wall instead of being on the floor, despite the care plan and physician orders specifying that floor mats should be in place on both sides of the bed during the day and evening shifts. Interviews with staff, including a CNA and an LVN, confirmed that it was their responsibility to ensure the mats were correctly positioned and that the resident required both mats to prevent injury due to her history of unassisted bed exit attempts. The Director of Nursing also acknowledged that the absence of the mat could result in injury and that staff were responsible for monitoring the placement of preventive devices. The facility's fall prevention policy required assessment and implementation of interventions such as adaptive equipment to minimize falls and injuries, but this was not followed in this instance.
Failure to Administer Oxygen at Ordered Flow Rate
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards, physician orders, and the resident's care plan for a resident with chronic obstructive pulmonary disease (COPD) and hypoxia. The resident was ordered to receive oxygen at 2 liters per minute via nasal cannula as needed to maintain oxygen saturation above 92%. However, observations on two separate occasions found the resident's oxygen concentrator set at 3 liters per minute. The resident reported she could apply and remove the oxygen tubing but did not adjust the concentrator settings herself. Interviews with staff revealed that a CNA was unaware of the resident's prescribed oxygen amount and did not adjust the settings, stating that nurses were responsible for this task. An LVN admitted he had not checked the oxygen concentrator settings during his shift and was initially unsure of the correct order, only confirming it after reviewing the physician's documentation. The DON confirmed that nurses are responsible for verifying oxygen settings at the start of their shifts and acknowledged the importance of adhering to physician orders, especially for residents with COPD. Facility policy required verification and correct administration of oxygen as per physician orders.
Expired Biologicals and Medical Supplies Not Discarded
Penalty
Summary
Surveyors observed that the facility failed to dispose of expired biologicals in both medication rooms reviewed. In the 100-hall medication room, there were 19 expired swab kits, including wound, buccal, and vaginal swabs, as well as a glucagon pen and a urine-vaginal-STI kit, all past their expiration dates. In the 200-hall medication room, an expired enteral feeding tube de-clogger device was found. These expired items were not removed from storage, despite not being used for several years due to a change in lab companies. During an interview, the Assistant Director of Nursing (ADON) acknowledged that the expired sterile swabs had lost their sterility and could alter test results if used. She stated that someone could have unknowingly used the expired swabs, which could introduce bacteria to residents. The ADON admitted responsibility for checking the medication rooms but had not considered removing the swabs since the facility had switched lab companies. A policy for expired biologicals was requested but not provided.
Failure of Registered Dietician to Attend Weekly Weight Meetings and Provide Required Oversight
Penalty
Summary
The facility failed to ensure that the registered dietician (RD) attended weekly weight meetings as required, which is necessary for monitoring and addressing residents' dietary needs. Interviews with the ADON and Dietary Manager (DM) revealed that the RD primarily attended monthly meetings and rarely, if ever, participated in the weekly weight meetings, either in person or by phone. The DM and ADON confirmed that the RD had not provided in-services or training to dietary staff, and the DM was responsible for updating preference cards and likes/dislikes. The RD stated she visited the facility weekly but could not verify her on-site visits and had limited direct interaction with residents, typically only those with trending weight loss. Sign-in sheets for weekly meetings were requested but not provided, and kitchen in-service records showed no RD involvement. The facility's agreement with the consultant dietician required the RD to provide guidance, training, and inspections of the dietary department, including sanitation and food service operations, but these responsibilities were not fulfilled as documented. The RD was also expected to be available at various mealtimes to observe dining operations and to be present for surveys if requested. The lack of RD participation in weekly weight meetings and absence from staff training and in-services contributed to the deficiency, potentially impacting the facility's ability to meet residents' dietary needs as outlined in their care plans.
Failure to Accurately Document and Monitor Blood Pressure Prior to Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who was prescribed a blood pressure medication with specific hold parameters. Licensed vocational nurses (LVNs) did not consistently check or document the resident's blood pressure prior to administering the medication, as required by the physician's order. On multiple occasions, blood pressure readings were either not taken or not recorded, yet the medication was still administered and the same blood pressure values were repeatedly documented on the electronic medication administration record (eMAR). The resident involved was an adult male with a history of hypertension, hyperlipidemia, peripheral vascular disease, and type 2 diabetes. His care plan included interventions to avoid taking blood pressure readings after physical activity or emotional distress and to administer antihypertensive medications as ordered, monitoring for side effects and effectiveness. Despite these interventions, the review of the resident's records showed that blood pressure was only checked on 9 out of 24 days when the resident was present and received his medication. On several days, the same blood pressure readings were documented without evidence that the measurements were actually taken, and in some cases, blood pressure readings were recorded even when the resident was not in the facility. Interviews with facility staff confirmed that nurses were expected to follow medication administration parameters and document vital signs as required. One LVN admitted to not always checking blood pressure before administering medication and could not provide a reason for this lapse. The Assistant Director of Nursing also stated that the expectation was for nurses to follow orders and document appropriately. The facility's own policy and professional nursing standards emphasize the importance of accurate documentation and adherence to medication administration protocols.
Failure to Maintain Safe and Sanitary Kitchen Environment Due to Water Leaks and Equipment Issues
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment in the kitchen, as evidenced by water dripping from an electrical conduit box and a lighting fixture in the ceiling above the stove, as well as from a nearby AC return. Observations revealed ongoing water damage, including swollen and gaping sheetrock around the AC return in the DM's office. The maintenance staff (MS) acknowledged that condensation had been dripping for about three months and attempted to patch the area, but was unaware that the water continued to drip. The MS also noted that filling the holes in the electrical conduit box could cause condensation to accumulate inside, potentially sparking with electrical wires. Additionally, the administrator (ADM) reported a water heater issue, with a plumber initially stating the heater was fine, but later discovering it was not heating. As a result, paper dishes were used because the water was not hot enough to sanitize dishware, which could pose a risk to residents. Facility policy and FDA Food Code guidelines require ceilings to be free from water to prevent contamination, but these standards were not met in the kitchen area.
Inaccurate Documentation of Narcotic Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, specifically in documenting the administration of narcotic medications. For Resident #3, there were discrepancies in the electronic medication administration record (eMAR) for Lorazepam, Tramadol, and ABH gel, with multiple instances of these medications being administered but not documented. This resident, who had severe cognitive impairment and was on a pain management plan, received these medications without proper documentation, which could lead to improper medication administration. Resident #4 also experienced similar issues with documentation. The eMAR did not accurately reflect the administration of Acetaminophen with codeine and Tramadol, with numerous instances of these medications being given but not recorded. This resident, who had a history of amputations and phantom limb pain, was on a pain management plan that required careful monitoring and documentation of medication effectiveness and side effects. Resident #5's records showed discrepancies in the documentation of Ativan administration. Despite being cognitively intact, the resident's eMAR did not accurately reflect the administration of this antianxiety medication. Interviews with nursing staff revealed that documentation lapses were often due to being busy or sidetracked, which could lead to medication errors. The facility's policies on medication administration and documentation were not consistently followed, contributing to these deficiencies.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from abuse, neglect, and exploitation, as evidenced by an incident involving two residents. Resident #1, a female with severe cognitive impairment and a history of wandering due to dementia, was involved in an altercation with Resident #2. Resident #1 wandered into Resident #2's room, leading to a physical confrontation where Resident #2 pushed Resident #1, causing her to fall and sustain a head injury. Resident #2, who has moderate cognitive impairment and a history of schizophrenia and schizoaffective disorder, was documented to have behavior problems, including physical and verbal aggression. Prior to the incident, interventions were in place to manage Resident #2's behavior, such as encouraging appropriate expression of feelings and providing psychiatric services. However, these measures were insufficient to prevent the altercation with Resident #1. The incident was reported, and staff interviews revealed that Resident #1 was often redirected due to her wandering behavior, but this was not always effective. Resident #2 had previous incidents of aggression, and staff were aware of her condition and the voices she reported hearing. Despite in-service training on abuse and neglect, the facility's measures were inadequate to prevent the incident, highlighting a deficiency in ensuring resident safety and protection from abuse.
Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect a resident from the misappropriation of her medications, specifically lorazepam and tramadol, which are controlled substances. The resident, who was admitted with severe cognitive impairment and a history of anxiety and pain, had her medications misappropriated during a transfer from one hall to another within the facility. The transfer process was not properly managed, leading to the loss of 7 lorazepam tablets and 19 tramadol tablets. The incident involved multiple staff members, including LVNs and ADONs, who were responsible for transferring and securing the resident's medications. The medications were initially placed in a purple bag by one LVN and handed over to another staff member without proper documentation or verification of the narcotic count. The bag was later found in an unsecured cabinet, and the narcotic log sheets were misplaced, leading to confusion and the eventual discovery of the missing medications. Interviews with staff revealed inconsistencies in the handling and documentation of the resident's medications. The facility's procedures for transferring and securing narcotics were not followed, and there was a lack of communication and accountability among the staff involved. The DON and ADONs conducted an investigation, which included reviewing video footage and obtaining statements from the staff, ultimately leading to the suspension and termination of one LVN whose actions did not align with the facility's expectations.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, leading to an accident. A CNA provided incontinent care to a resident without the required assistance of a second staff member, resulting in the resident rolling off the bed and sustaining injuries. The resident, who had multiple diagnoses including cerebral palsy, Parkinson's, and intellectual disabilities, was dependent on staff for all activities of daily living and required two-person assistance for bed mobility. The resident's care plan clearly indicated the need for two-person assistance during bed mobility and other activities due to her high fall risk and physical impairments. Despite this, the CNA attempted to perform the care alone, which directly led to the resident falling from the bed. The incident was witnessed by other staff members, and the resident was subsequently taken to the hospital for evaluation, where no fractures were found, but she experienced pain and soreness. Interviews with staff and the resident confirmed that the care plan was not followed, and the CNA involved was aware of the requirement for two-person assistance. The facility's policies on activities of daily living and fall prevention were not adhered to, resulting in the resident's fall and injury. The incident highlights a lapse in following established care protocols, which are crucial for the safety and well-being of residents with significant care needs.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely in a medication room on Hall 300. During an observation, it was noted that the medication room door was left open and unlocked for five minutes while LVN A was assisting a resident with sit-to-stand equipment in another room. Although the refrigerator and the tub of discontinued medications were locked, the medication room itself was not secured, which is against the facility's policy. Interviews with LVN A and the Director of Nursing confirmed that the expectation was for all medication room doors to be closed and locked at all times. LVN A acknowledged that she thought she had locked the door before leaving the area. The facility's medication policy, revised in November 2020, clearly states that all compartments containing drugs and biologicals must be locked when not in use, and only authorized personnel should have access to these medications.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a deficiency in accommodating the needs and preferences of residents. The resident, who was observed in her room in a wheelchair with the door closed, did not have access to her call light, which was attached to the side of the bed. This resident had a history of hemiplegia and hemiparesis following a stroke, vascular dementia, lack of coordination, and abnormalities in gait and ambulation. The resident's care plan indicated a need for assistance from 1-2 staff members for transfers and highlighted the importance of having the call light within reach due to the risk of falls. The incident occurred when LVN B transported the resident to her room after lunch and left her without the call light while attending to a critical lab result for another patient. LVN A acknowledged the risk of leaving the resident without the call light, noting that the resident could have fallen. The Director of Nursing and the Administrator both confirmed that the resident should not have been left without the call light and that LVN B, a new staff member, was being educated on proper procedures. The facility conducted an in-service training on ensuring call lights are within reach, attended by 25 staff members, including LVN B.
Kitchen Ventilation Issue and Lack of Maintenance Reporting
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen area, as observed during a survey. The kitchen ventilation system was dripping condensation from the ceiling onto the floor, creating a slipping hazard and potential for cross-contamination during food preparation. The Kitchen Manager was unaware of the dripping issue and believed there was no risk of cross-contamination since the water was not directly over the food preparation area. However, the Maintenance Director acknowledged the potential for cross-contamination and was also unaware of the issue, indicating a lack of communication and reporting of maintenance needs. The Maintenance Director mentioned that kitchen staff are responsible for informing him of repair needs and that a work order book is available for reporting such issues. Despite this, a review of maintenance work orders from the previous month showed no records of any requests or completed work related to the kitchen ventilation system. The Administrator was also unaware of the condensation issue and downplayed the risk of cross-contamination, although he acknowledged the slipping hazard. The Assistant Director of Nurses confirmed that the kitchen serves all residents except one who is on NPO status and has a feeding tube.
Incomplete Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, as evidenced by the incomplete documentation of a fall incident involving a resident. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction, experienced an assisted fall in the shower room. Despite the incident, there was no documentation in the resident's clinical records, care plan, progress notes, or incident history list regarding the fall. Interviews with staff revealed that the fall was not properly reported or documented. CNA A, who was present during the fall, stated that she assisted the resident to the floor and informed a nurse, but could not recall who the nurse was. CNA C, who responded to the call light, helped CNA A pick up the resident but did not witness the fall or notify anyone, assuming CNA A would report it. The DON and Administrator were unaware of the incident until surveyor intervention, indicating a breakdown in communication and documentation processes. The facility's policy on accidents and incidents was not followed, as the required notifications and documentation were not completed. LVN G, who was responsible for documenting the incident, admitted to starting but not finishing the documentation and failing to notify the DON or ADON. The lack of proper reporting and documentation could negatively impact residents, as it prevents appropriate assessment and intervention following incidents.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by multiple deficiencies observed during a survey. The survey revealed significant water damage in resident rooms, particularly in the closets where sheetrock was bubbling and soft, baseboards were buckling, and plywood ceilings were removed, exposing air conditioning ductwork. Additionally, several rooms had missing or difficult-to-open closet doors, stained bathroom floors, leaking toilets, and exposed electrical cords. The thermostat in one room was found dangling from the wall, and a bedside dresser was missing parts. The smoking area was also found to be inadequately maintained, with metal butt cans containing water, trash, and cigarette butts, and discarded cigarette butts scattered on the ground. The facility's maintenance log showed that work orders were signed off as completed despite the issues persisting, such as broken and stained ceiling tiles, missing dresser handles, and bulging closet walls. Interviews with staff revealed that they believed the work orders were completed, but observations indicated otherwise. Interviews with residents and staff highlighted concerns about the facility's condition, with reports of leaking water, potential mold growth, and inadequate cleaning practices. The facility's administrator acknowledged the issues and had initiated a 90-day plan to address the deficiencies, but the survey findings indicated that the environment remained unsafe and uncomfortable for residents.
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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