Sunflower Park Health Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Kaufman, Texas.
- Location
- 1803 Highway 243 East, Kaufman, Texas 75142
- CMS Provider Number
- 675390
- Inspections on file
- 25
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Sunflower Park Health Care during CMS and state inspections, most recent first.
Three residents continued to receive psychotropic medications at higher doses despite pharmacy and physician recommendations for gradual dose reductions. In each case, the required dose reductions were either not implemented or not documented, and staff interviews revealed a lack of oversight and awareness regarding these medication changes.
Several residents reported receiving cold meals, and surveyors confirmed that food items served during a lunch meal were not at appropriate temperatures. The Dietary Manager acknowledged ongoing complaints and identified delays in meal distribution as a contributing factor, with no effective resolution implemented despite reporting the issue to facility leadership.
Staff failed to hold and serve hot foods, including regular and pureed corn and pureed chicken strips, at the required temperature of 140°F or above. Food was served at temperatures between 130°F and 132°F, contrary to facility policy and professional standards, and staff did not reheat the food before serving.
Three residents had personal refrigerators filled with undated food items and no visible thermometers, with no clear staff responsibility for monitoring temperatures or cleanliness. Staff interviews revealed confusion about who was responsible for these tasks, and temperature logs showed potentially inaccurate readings despite the absence of thermometers. The facility's policy placed responsibility on residents and families, but lack of enforcement led to improper food storage and monitoring.
Staff failed to follow proper infection control procedures, including not changing gloves or performing hand hygiene during incontinent care for a resident, and not using required PPE or posting enhanced barrier precaution signage for two residents with wounds. Nursing management did not ensure that EBP signage and PPE carts were in place, and care plans and physician orders did not reflect EBP requirements, contrary to facility policy.
Two residents with intact cognition and significant care needs reported that a CNA was rude to them, specifically refusing to provide coffee to one resident due to a previous spill and speaking disrespectfully to both. These concerns were reported to nursing staff and corroborated by another CNA, with management being made aware. The facility's policy requires all residents to be treated with respect and dignity.
A resident with a diagnosis of schizophrenia and moderate cognitive impairment received the antipsychotic medication Invega Sustenna without documented informed consent or completion of the required consent form. Staff interviews confirmed that consent was not obtained or documented, and the resident reported not being informed about the medication's risks and benefits, despite facility policy requiring such consent and education.
Two rooms were found with environmental deficiencies: one with a privacy curtain rod hanging loose from the ceiling, which had been reported by a resident multiple times but not addressed, and another with an unapproved electrical extension cord in use for a resident's phone charger. Multiple staff, including the Maintenance Director, LVN, Medication Aide, Administrator, and DON, were unaware of these issues, and facility records indicated such items were not permitted.
Two residents did not have their MDS assessments accurately coded—one with a developmental disability was not marked as PASRR positive, and another receiving hospice care was not identified as such in the assessment. These errors were attributed to data entry mistakes and oversight by the MDS Coordinator, despite supporting documentation in the medical records and care plans.
A resident with multiple diagnoses, including bipolar disorder and dementia, was not referred for a required PASRR Level II evaluation due to inaccurate completion and review of PASRR Level 1 screening forms. The resident's mental health status was not properly documented in the PASRR process, and staff responsible for PASRR screenings did not identify or correct the error, resulting in the resident not being evaluated for specialized services.
A resident with multiple mental health diagnoses, including schizophrenia and depression, was admitted with a PASRR Level I screening indicating mental illness, but the required PASRR Level II evaluation was not completed. Facility staff confirmed the omission, and policy requiring timely review and submission of PASRR forms was not followed.
Two residents with complex medical needs did not have baseline care plans developed within 48 hours of admission, as required by facility policy. Staff interviews revealed confusion about responsibility for initiating and completing these care plans, resulting in incomplete documentation and a lack of clear instructions for providing person-centered care.
Two residents with significant medical and cognitive needs were not provided with activities tailored to their preferences and abilities, as required by their assessments and care plans. One resident, who enjoyed Bingo and required assistance, was not taken to activities or offered in-room options, while another, with severe cognitive impairment, was not provided with preferred reading materials or music and received no one-on-one activities. Staff interviews and documentation confirmed that activity needs were not addressed for these residents.
A resident with multiple chronic conditions did not receive accurate skin assessments or appropriate wound care due to incomplete documentation and failure to follow facility protocols. The Treatment Nurse did not assess or document all skin issues, resulting in missed treatment orders for a wound on the right great toe, despite facility policy requiring comprehensive weekly skin assessments.
Two residents were placed at risk when one had an unsecured oxygen cylinder left in her room, contrary to facility policy, and another experienced a fall due to a loose bolt on her wheelchair backrest. Staff interviews revealed a lack of systematic safety checks for wheelchairs and inconsistent reporting of maintenance concerns, with no policy in place for equipment repair and maintenance.
A resident with multiple health conditions had a suction machine in her room without a physician order, and the yankauer was repeatedly observed unbagged and improperly stored. The use of the suction machine was not included in the care plan, and staff confirmed these omissions, acknowledging that proper procedures were not followed.
A resident with multiple chronic conditions continued to receive a higher dose of Omeprazole despite a pharmacy recommendation, approved by the physician, to reduce the dose. The DON and ADON were responsible for processing the medication change but did not implement the new order, and staff could not explain the oversight. The facility's policy on handling such recommendations was not provided during the survey.
A resident with multiple health conditions and moderate cognitive impairment was found to have wound care medications and barrier creams unsecured in her room, rather than stored in the medication cart as required. Staff interviews and policy review confirmed that these medications should have been locked and properly labeled, but were left accessible on top of the resident's refrigerator.
A resident with COPD and cancer, who was cognitively intact and receiving hospice services, did not have essential hospice documentation maintained in the clinical record. Required forms, nurses' notes, and physician orders were missing, and staff interviews revealed a lack of verification and follow-through to ensure hospice documents were present and care was coordinated.
A CMA diverted a resident's prescribed Ondansetron, as evidenced by a photo of the medication blister pack found outside the facility and text messages indicating intent to distribute medications. The resident, who had severe cognitive impairment and required extensive assistance, was at risk for not receiving her needed medication. Facility leadership confirmed this act was against policy and constituted drug diversion.
A resident with a history of trauma and moderate cognitive impairment was subjected to abuse and neglect when multiple staff members held her down to provide incontinent care against her will. Despite the resident's protests and distress, the staff continued the care, believing they were required to do so. The incident revealed a failure to adhere to the facility's policies on abuse, behavioral management, and restraint, as staff did not stop care or report the incident as required.
The facility failed to provide trauma-informed care for three residents with histories of trauma, including a resident who was held down and changed against her will, despite her protests. The care plans for these residents did not adequately document their trauma histories or potential triggers for re-traumatization, leading to deficiencies in their care.
A resident with severe cognitive impairment and Parkinson's disease suffered second-degree burns after spilling hot coffee on herself. The facility failed to adhere to its policy of serving coffee at a safe temperature, leading to the incident. The coffee was served at 158 degrees Fahrenheit, exceeding the guideline of 140 degrees Fahrenheit, which contributed to the resident's injury.
The facility's kitchen failed to meet food safety standards, with issues such as improper food labeling, incorrect use of hair restraints, and unsanitary equipment. Staff interviews revealed non-compliance with hygiene protocols, including improper handwashing and equipment storage. Despite existing policies, these practices were not consistently followed, posing a risk of cross-contamination and foodborne illness.
A long-term care facility failed to maintain an effective infection prevention and control program, affecting several residents. Staff did not perform proper hand hygiene or use PPE as required, risking infection spread. A CNA did not clean a resident's peri area properly, an LVN skipped hand hygiene after a blood sugar check, and another CNA mishandled wipes during care. The DON and a NA entered a resident's room without proper PPE, and a laundry aide transported clean clothing on an uncovered cart.
The facility failed to maintain resident dignity and respect, affecting three residents. One resident was upset after being called 'big girl' by the Administrator and was told by CNAs that washing her hair was too time-consuming. Another resident was reportedly told to 'shut up' by a CNA, and a third resident felt pressured by a CNA to clean herself, who then left her with her pants down.
The facility failed to address grievances raised by the resident council regarding untimely responses to call lights. Despite repeated concerns from residents over several months, there was no documentation of grievances filed or actions taken. The facility's grievance policy was not followed, and the issue remained unresolved, partly due to turnover in the Administrator position.
The facility failed to ensure the activities program was directed by a qualified professional. The Activity Director, hired without certification, was given six months to obtain it. Other staff, also uncertified, assisted in scheduling activities. The ADO confirmed the state requirement for certification, but the Activity Director was not monitored. The facility's policy on activities was not provided upon request.
The facility failed to provide palatable and appetizing meals for 16 residents, as reported during a resident group meeting. Observations on a sampled lunch tray revealed lukewarm buttered noodles, cool carrots, and a vinegary-tasting honey roll. The Dietary Manager had not received recent complaints but acknowledged past issues. The Regional Compliance Nurse confirmed the absence of a policy on meal palatability, while the Area Director of Operations emphasized the dietary department's responsibility for ensuring meal quality.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in meeting their medical and psychosocial needs. One resident's self-catheterization was not included in her care plan, another's history of trauma was omitted, and a third resident's wound care and diabetes management were not accurately reflected. These oversights were acknowledged by the facility's staff, highlighting the importance of accurate and updated care plans.
The facility failed to maintain accurate records and reconciliation of controlled drugs, as unlogged medications were found in storage awaiting disposal. The DON admitted the medication log was not up to date, risking medications going missing. The process required logging and secure storage, which was not followed.
The facility failed to properly label and store medications, with an unlocked treatment cart and undated medications on Hall C's nurse cart. Several residents' medications, including insulin and inhalers, were open and undated, and expired Diazepam suppositories were found in the medication room refrigerator. The DON and ADON emphasized the importance of securing medication carts and dating medications to ensure their effectiveness.
Two residents requiring nectar-thickened liquids due to swallowing difficulties were served incorrect liquid consistencies, risking aspiration and choking. A CNA and dietary aide failed to ensure the correct thickness, with the dietary aide 'eyeballing' the consistency instead of following prescribed methods. The facility's policy on thickened liquids was not followed, leading to this deficiency.
A resident with multiple health conditions did not receive fortified pudding as prescribed, due to staff's lack of adherence to dietary orders. The resident's care plan indicated a risk for malnutrition, but the dietary aide did not fortify the pudding, and the Dietary Manager was unaware of the issue. The ADON, DON, and Regional Director emphasized the importance of following dietary orders to prevent weight loss.
A facility failed to follow its smoking policy by not ensuring a resident wore a required smoking apron during a supervised break and by allowing combustible materials in the smoking area. The staff member supervising was unaware of the apron requirement, and a propane grill was improperly present in the smoking area, violating the facility's policy.
A resident with a history of neurogenic bladder requiring daily in and out catheterization was not accurately reflected in the MDS assessment. Despite documentation of catheter use, the MDS Coordinator did not code it due to a lack of proof within the look-back period. The DON confirmed the resident's catheter use, and the ADO stressed the importance of accurate MDS coding for care planning.
The facility failed to follow physician orders for wound care for a resident, leading to a delay in treatment and potential risk of infection. Additionally, two CNAs did not report an unwitnessed fall of another resident to the charge nurse, delaying necessary assessment and care. These actions were contrary to professional standards and the facility's policies.
A facility failed to provide a resident with the necessary supplies and education for self-catheterization, despite her medical history of neurogenic bladder and urinary tract infections. The resident did not have access to essential items like gloves and hand sanitizer, and her care plan did not reflect her need for self-catheterization. Interviews revealed that staff were unaware of the resident's needs and had not provided proper education, leading to a deficiency in care.
A CNA at the facility failed to demonstrate competency in infection control and incontinent care, as observed during care for a resident with ovarian cancer and COPD. The CNA did not perform proper hand hygiene, used dirty gloves on clean items, and inadequately cleaned the resident. The CNA was not properly trained or observed by management, and competency checks were not adequately completed or documented.
The facility exceeded the acceptable medication error rate with a 5.26% error rate due to improper insulin administration for two residents. LVNs failed to prime insulin pens before administration, leading to potential dosing inaccuracies. Interviews revealed a lack of awareness and training on proper insulin pen use, contributing to the errors.
The facility failed to provide timely lab services for two residents, leading to deficiencies in care. A resident with diabetes did not receive a scheduled A1C test, and another resident with multiple diagnoses missed a potassium re-draw. The DON was unaware of these lapses until surveyor intervention, revealing a breakdown in the lab system and failure to follow the facility's physician order policy.
A resident in a LTC facility, who was cognitively impaired and required total assistance, did not have access to a call light system. Observations confirmed the absence of a call light, and staff interviews acknowledged the oversight, highlighting the risk of delayed assistance. Despite the facility's policy, no call light policy document was provided.
Failure to Implement and Document Gradual Dose Reductions for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications underwent required gradual dose reductions (GDRs) and behavioral interventions, unless clinically contraindicated, as part of efforts to discontinue these drugs. For three residents reviewed, there were lapses in following through with pharmacy recommendations and physician-approved dose reductions. Specifically, one resident with dementia and major depressive disorder continued to receive a higher dose of citalopram despite a physician-approved reduction, with the dose only being adjusted after surveyor intervention. Medication administration records confirmed the resident received the higher dose for over a month after the reduction was approved. Another resident with paranoid schizophrenia and depression was supposed to have their duloxetine dose reduced from 60 mg to 40 mg following agreement from a psychiatric nurse practitioner, but records showed the reduction was never implemented. The medication administration records indicated the resident continued to receive the higher dose for several months after the recommendation and approval for reduction. A third resident with bipolar disorder and schizophrenia was prescribed Invega Sustenna and olanzapine. Although pharmacy recommendations for GDRs were made, there was no documentation that these reductions were attempted or that behavioral interventions were implemented. Interviews with facility staff, including the ADON, DON, and Administrator, revealed a lack of awareness and oversight regarding the pharmacy recommendations and the status of GDRs. The facility's own policy required documentation of GDR attempts and outcomes, but such documentation was missing for these residents.
Failure to Serve Food at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for residents during a reviewed lunch meal. Multiple residents reported receiving cold food, and direct observation by surveyors and the Dietary Manager confirmed that the chicken fried chicken was lukewarm, while the mashed potatoes and corn were cold. The Dietary Manager acknowledged that the food items were not at the appropriate temperature and stated that she had received similar complaints from residents in the past. She also indicated that the food was hot when it left the kitchen, but delays in meal distribution by staff resulted in residents receiving cold meals. Interviews revealed that the issue of cold food had been reported to the Administrator, DON, and previous Administrators, but no resolution had been implemented. The Dietary Manager suggested the use of closed carts to keep meals warmer, but this suggestion was not acted upon. The Administrator confirmed that the nursing department was responsible for ensuring timely delivery of meals to residents and acknowledged that cold food would not be appetizing. Review of the facility's policy indicated that food should be served at the proper temperature and in an attractive manner, which was not achieved during the observed meal service.
Failure to Maintain Proper Food Holding Temperatures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, it was found that regular texture corn, pureed corn, and pureed chicken strips were being held at temperatures below the required 140°F on the steam table. Specifically, the foods were measured at 130°F and 132°F. Staff interviews confirmed that food should be held at or above 140°F, and if not, it should be reheated to at least 165°F before serving. However, the staff member responsible for serving the trays did not reheat the food, stating she was focused on starting meal service and did not consider reheating at the time. The Dietary Manager and Administrator both acknowledged that food should be held at the proper temperature, with the Dietary Manager preferring 165°F and confirming that food not at the correct temperature should be reheated. The facility's policy also requires that all hot foods be cooked and held for service at 140°F or above, and any food not meeting this standard should be reheated to 165°F. Despite these policies and expectations, the food was served at temperatures below the required threshold, and the Dietary Manager stated she had not previously observed incorrect food temperatures.
Failure to Monitor and Maintain Safe Storage of Resident Food in Personal Refrigerators
Penalty
Summary
The facility failed to implement and enforce a policy regarding the use and storage of foods brought to residents by family and other visitors, specifically in relation to the monitoring and maintenance of personal refrigerators in resident rooms. Observations revealed that three residents had personal refrigerators that were packed with undated food items and lacked visible thermometers. Interviews with these residents indicated that they were either unsure of who was responsible for checking the refrigerator temperatures or believed that no one was regularly monitoring them. Review of temperature logs showed consistent, possibly inaccurate temperature recordings, despite the absence of thermometers in the refrigerators during the survey period. Staff interviews demonstrated confusion and lack of clarity regarding responsibility for monitoring and maintaining the cleanliness and temperature of residents' personal refrigerators. Various staff members, including LVNs, maintenance, housekeeping, and CNAs, provided conflicting statements about who was responsible for these tasks. The housekeeping supervisor mentioned keeping a temperature log and attempting to clean the refrigerators but noted that residents sometimes refused access. The administrator and DON both acknowledged the importance of monitoring refrigerator temperatures but also indicated uncertainty about which staff were assigned to this duty. A review of the facility's Food and Nutrition Services policy revealed that the responsibility for monitoring the interior temperature of personal refrigerators was assigned to residents and/or their family members, with a requirement to keep food at 40 degrees Fahrenheit or less and to discard perishable foods within seven days. However, the lack of enforcement and oversight of this policy led to the deficiency, as evidenced by the absence of thermometers, undated food items, and inconsistent temperature monitoring in the residents' personal refrigerators.
Failure to Implement and Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed deficiencies in staff practices and lack of proper implementation of enhanced barrier precautions (EBP) for residents with wounds or indwelling devices. One incident involved a certified nursing assistant (CNA) who did not change gloves or perform hand hygiene appropriately while providing incontinent care to a resident with cerebral palsy and frequent incontinence. The CNA used the same gloves to clean the resident, apply a clean brief, assist with dressing, handle the resident's wheelchair and walker, search through drawers, and brush the resident's hair, before finally removing the gloves and performing hand hygiene outside the room. The CNA acknowledged the lapse and understood the correct procedure, attributing the failure to nervousness. Interviews with facility leadership confirmed that glove changes and hand hygiene are required at specific points during care, and that failure to do so could result in infection and cross-contamination. Another deficiency was observed during wound care for a resident with dementia, chronic heart failure, and chronic kidney disease. The treatment nurse and the DON entered the resident's room to provide wound care without donning gowns, and only wore gloves. There was no EBP signage on the door, nor was there a PPE cart available outside the room. The resident's care plan did not include EBP, and there was no physician order for EBP in the resident's medical record. The facility's policy requires EBP for residents with wounds or indwelling devices, and communication to staff should occur via postings and electronic records. Additionally, another resident with chronic kidney disease and impaired cognitive function did not have EBP signage or a PPE cart outside her room, despite having orders for wound care. Observations on multiple occasions confirmed the absence of required signage and PPE. Interviews with the ADON, Administrator, and DON revealed that nursing management was responsible for ensuring EBP signage and PPE carts were in place, but these measures were not implemented. The DON admitted to forgetting to follow up on obtaining PPE carts. Facility policies reviewed indicated that EBP should be used for residents with wounds or indwelling devices, and that staff should be notified through postings and electronic records.
Failure to Treat Residents with Dignity and Respect by CNA
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as required by resident rights regulations. Both residents had intact cognition and required varying levels of assistance with activities of daily living. One resident, who had hemiplegia and major depressive disorder, reported that a CNA was rude to him and his roommate, specifically citing an incident where the CNA refused to provide coffee to his roommate because he had spilled it the previous day. The resident stated he reported the CNA's behavior to a registered nurse. The second resident, who had chronic obstructive pulmonary disease and generalized anxiety disorder, also reported that the CNA was rude and refused to give him coffee due to a previous spill. He stated that he informed the RN about the CNA's refusal and rudeness, after which the RN provided him with coffee. Both residents described the CNA's manner of speaking and tone as disrespectful, and these concerns were corroborated by another CNA, who confirmed that the residents had reported the CNA's rudeness to her and that management was aware of these reports. Interviews with staff, including the RN, CNA, DON, and Administrator, revealed that the residents' complaints about the CNA's rudeness and refusal to fulfill their requests were known to some staff members. The CNA denied being rude and stated she was waiting to assist the resident into his chair before providing coffee. The DON and Administrator acknowledged expectations for staff to treat residents with dignity and respect, and recognized that failure to do so could negatively affect residents' well-being. The facility's policy requires all residents to be treated with respect and dignity, and to have their individuality recognized.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided written consent prior to the administration of an antipsychotic medication, Invega Sustenna, as required. Record reviews showed that the resident, who had a diagnosis of paranoid schizophrenia and a moderately impaired cognitive status, received the medication over several months without a completed HHSC Form 3713 or other documented consent in the electronic health record. Interviews with facility staff, including the Regional Compliance Nurse, ADON, DON, and administering RN, confirmed that no consent was obtained or documented for this medication. The resident herself reported not being asked to sign a consent for Invega Sustenna and not being informed about the risks and benefits of the medication. Facility policy required that residents be informed of and participate in their treatment, including being made aware of the risks, benefits, and alternatives to psychotropic medications before initiation. Despite this, the required consent process was not followed for this resident. Staff interviews revealed a lack of awareness regarding the missing consent, and the resident's care plan indicated the need for education about the medication, which was not documented as provided. The deficiency was identified through interviews, record reviews, and policy examination, all indicating a failure to obtain and document informed consent for the administration of a psychoactive medication.
Failure to Maintain Safe and Functional Resident Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in two of eight rooms reviewed. In one room, the privacy curtain rod was observed hanging from the ceiling and not properly secured, with approximately 15 inches detached. One resident stated she had not reported the issue, but her roommate had reported it multiple times to staff, though she could not recall specific staff members or dates. Multiple staff members, including the Maintenance Director, LVN, and Medication Aide, were unaware of the loose curtain rod, and the issue was not documented in the facility's Champion Rounds log. The Administrator and DON were also unaware of the problem, despite daily room rounds being conducted by administrative staff and separate rounds by the Maintenance Director. In another room, an electrical extension cord was found in use for a resident's phone charger. The resident stated the extension cord was hers and that no one had informed her it was not allowed. Staff members, including the LVN and Medication Aide, were unaware of the extension cord's presence and acknowledged that extension cords were not permitted due to fire hazard concerns. The Administrator confirmed that extension cords were not allowed unless approved and was not aware of any residents using them. The DON also stated that the presence of the extension cord should have been identified during Champion Rounds. Facility records indicated that extension cords and multiple plugs are not allowed in resident rooms.
Inaccurate MDS Assessments for PASRR and Hospice Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with cerebral palsy and a developmental disability, the Comprehensive MDS assessment did not indicate her Level II PASRR status, despite documentation in her care plan and PASRR evaluation confirming she was PASRR positive. For another resident with chronic obstructive pulmonary disease and generalized anxiety disorder, the Quarterly MDS assessment did not reflect that he was receiving hospice services, even though his order summary, care plan, and hospice documents all indicated he had been admitted to hospice care. Interviews with the MDS Coordinator revealed that these inaccuracies were due to data entry errors and oversight, with the Coordinator acknowledging awareness of the correct statuses but failing to code them properly. The facility relied on spot checks and audits for oversight, but not every MDS assessment was reviewed. The Administrator confirmed that the MDS Coordinator was responsible for accurate completion of assessments and that errors in coding could affect residents' function and diagnoses. The Regional Compliance Nurse stated there was no specific policy for MDS accuracy, and that the facility followed the RAI manual.
Failure to Refer Resident with Bipolar Disorder for Required PASRR Level II Evaluation
Penalty
Summary
The facility failed to refer a resident with a diagnosis of bipolar disorder for a Level II PASRR evaluation upon admission and following a significant change in status assessment. The resident, an elderly female with multiple diagnoses including chronic kidney disease, Parkinson's disease, bipolar disorder, anxiety disorder, major depressive disorder, dysphagia, dementia, hypertension, and heart failure, was admitted and re-admitted to the facility with these conditions documented in her records. Despite the presence of a qualifying mental health diagnosis, the PASRR Level 1 screening completed by the referring entity did not indicate a mental illness, and no corrected Level 1 or Level 2 PASRR evaluation was completed for the resident. Review of the resident's comprehensive MDS assessment showed that the section for serious mental illness was left blank, even though the diagnosis of bipolar disorder was present in the medical record and care plan. The resident's BIMS score indicated moderate cognitive impairment, and the care plan included a focus on mood problems related to bipolar disorder and impaired cognitive function. However, the PASRR documentation failed to reflect the resident's mental health status accurately, and the necessary referral for a Level II evaluation was not made. Interviews with facility staff revealed that the MDS Nurse, who was responsible for PASRR screenings, was unaware that the initial Level 1 screening was incorrect and did not initiate a Level II evaluation as required. The Administrator and DON both acknowledged that accurate identification and coding of PASRR status is essential for ensuring residents receive appropriate services, and that the nursing team is responsible for this process. Facility policy requires review and submission of PASRR forms prior to admission, but this process was not followed in this case, resulting in the deficiency.
Failure to Complete PASRR Level II Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected a resident's status and did not complete a required PASRR Level II evaluation for a resident identified as having a mental illness. The resident, a female with diagnoses including schizophrenia, mood affective disorder, and depression, was admitted with a PASRR Level I screening indicating mental illness. Despite this, there was no evidence in the electronic medical record that a PASRR Level II evaluation was completed to determine eligibility for specialized services. Interviews with facility staff confirmed that the MDS Nurse, responsible for reviewing PASRR Level I screenings and submitting corrections or further evaluations, did not complete or submit the necessary PASRR Level II for the resident. The administrator and DON both acknowledged that the failure to complete the PASRR evaluation could result in the resident not receiving appropriate services. Facility policy required review and submission of PASRR forms prior to admission and prompt contact with the Local Authority for specialized services, which was not followed in this case.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, as required by facility policy and professional standards. For one resident with multiple diagnoses including cerebral infarction, anxiety disorder, polyneuropathy, peripheral vascular disease, and COPD, no baseline care plan was found in the electronic medical record. This resident required significant assistance with mobility, toileting, transfers, and dressing, and was cognitively intact. Interviews revealed confusion among staff regarding responsibility for initiating and completing baseline care plans, with the admitting nurse, DON, and MDS Nurse each cited as responsible at different times. The comprehensive care plan for this resident was not initiated until four days after admission. For another resident with diagnoses of diabetes mellitus, hypertension, heart failure, and depression, and who required maximal assistance for daily activities, no baseline care plan was completed upon admission. The resident was also cognitively intact and required set-up assistance for eating. Staff interviews indicated that the MDS Nurse was expected to complete the baseline care plan, while the DON was responsible for providing it to the family. The DON was unaware that the baseline care plan had not been completed and believed she had started the comprehensive care plan, but it was not finished. The care plan documentation was incomplete, only addressing surgical wound and medication monitoring, and not the resident's full needs. Record review confirmed that the facility's policy required a baseline care plan to be developed within 48 hours of admission, but this was not done for the two residents in question. Staff interviews consistently acknowledged the importance of the baseline care plan for communicating resident needs, but there was a lack of clarity and follow-through in ensuring these plans were completed as required.
Failure to Provide Individualized Activities Based on Resident Assessments
Penalty
Summary
The facility failed to provide activities based on comprehensive assessments and care plans that reflected the preferences and needs of residents, specifically for two residents reviewed for activities. One resident, an elderly female with chronic kidney disease, osteoarthritis, diabetes, COPD, hypertension, major depressive disorder, reduced mobility, and hand contractures, was not taken to activities after expressing interest, nor was she provided with in-room activities. Her care plan did not address activities, and there was no documentation of in-room visits or activity attendance, despite her stated enjoyment of Bingo and need for assistance to participate. Staff interviews confirmed that she rarely attended activities due to dialysis and mobility limitations, and that she had expressed sadness about missing activities she enjoyed. Another resident, an elderly female with chronic kidney disease, Parkinson's disease, bipolar disorder, anxiety disorder, major depressive disorder, dysphagia, dementia, hypertension, and heart failure, was not provided with one-on-one activities. Her care plan also lacked an activity focus area, and although her activity assessment indicated preferences for books, newspapers, magazines, and music, none of these were observed in her room during the survey period. She remained in her room with only a television for stimulation, and staff interviews indicated she rarely attended group activities and had not been identified for in-room visits by the new Activity Director. The facility's policy required that recreation programs be based on residents' interests and needs, and that those unable to participate in group settings be provided with individual programming. However, documentation and interviews revealed that these requirements were not met for the two residents in question, as their activity needs and preferences were not addressed in their care plans or through the provision of appropriate activities, either in-room or in group settings.
Failure to Provide Accurate Skin Assessments and Wound Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the Treatment Nurse did not document accurate skin assessments for the resident, and the resident was not provided treatment for a wound on the right great toe. The resident had multiple diagnoses, including dementia, major depression, chronic heart failure, chronic kidney disease, and high blood pressure, and required maximal assistance for most activities of daily living. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and no pressure ulcers or other skin conditions at the time of admission. The resident's care plan identified actual impairment to skin integrity, including a non-pressure area on the right great toe and a stage 2 intact blister on the top of the right foot, with interventions to provide treatment per orders. However, review of the order summary and skin assessments revealed inconsistencies and omissions. The Treatment Nurse's skin assessment documented the skin as intact, while another nurse's assessment on the same day noted a blister and scabbed areas on the toes. The wound evaluation documented a non-pressure wound on the right great toe with specific treatment orders, but these were not reflected in the order summary or implemented by the Treatment Nurse. Interviews with the Treatment Nurse, DON, ADON, and Administrator confirmed that the skin assessment was incomplete and did not include all areas of concern. The Treatment Nurse admitted to not performing a full assessment and not updating the care plan or entering necessary orders for wound care. Facility policy required a head-to-toe skin assessment for new admissions and weekly assessments for all residents, but this was not followed, resulting in the resident not receiving appropriate wound care.
Failure to Prevent Accident Hazards and Ensure Equipment Safety
Penalty
Summary
The facility failed to maintain a resident environment free from accident hazards for two residents. One resident had an unsecured oxygen cylinder lying in the corner of her room since admission, despite not having an order for or using oxygen. Multiple observations confirmed the cylinder remained in the room, and interviews with nursing and administrative staff acknowledged that the oxygen cylinder should have been stored in a designated storage area, not in the resident's room. Facility policy required that gas cylinders be handled only by trained personnel and stored securely, which was not followed in this instance. Another resident, who had a history of falls and required a wheelchair for mobility, experienced a fall due to a loose bolt on the backrest of her wheelchair. The maintenance logs showed no prior work order addressing this issue before the fall occurred. Interviews revealed that there was no established wheelchair safety check system in place at the time, and staff relied on an online referral system to report maintenance concerns. Some staff were not comfortable using the system, and there was no documentation of ongoing wheelchair safety checks for all residents. The facility did not have a policy regarding equipment repair and maintenance, and the lack of systematic checks and secure storage practices led to unsafe conditions for both residents. Staff interviews confirmed that the failures in reporting and monitoring contributed to the deficiencies observed, placing residents at risk for injury due to environmental hazards and equipment malfunction.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency occurred when a resident requiring respiratory care was not provided care consistent with professional standards. The resident, who had chronic kidney disease, hypertension, bipolar disorder, and moderate cognitive impairment, had a suction machine in her room without a corresponding physician order. The suction machine's yankauer was observed hanging outside of its bag on multiple occasions, rather than being properly bagged or removed after use. The resident reported using the suction machine occasionally and expressed concern about its cleanliness when not stored properly. Further review revealed that the use of the suction machine was not included in the resident's care plan, and staff interviews confirmed that there was no physician order for its use. Facility staff, including the RN, ADON, Administrator, and DON, acknowledged that the yankauer should have been bagged, an order should have been in place, and the care plan should have reflected the use of the suction machine. The facility's policy required proper assembly, use, and disposal of suctioning materials, as well as documentation of care, which was not followed in this case.
Failure to Implement Physician-Approved Pharmacy Recommendation for Medication Reduction
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically regarding the administration of Omeprazole, a proton pump inhibitor (PPI). The resident, who had multiple diagnoses including atherosclerotic heart disease, diabetes mellitus, dementia, osteoporosis, dysphagia, major depressive disorder, hypertension, and gout, had been receiving Omeprazole 40 mg daily since admission. Pharmacy recommendations dated 12/04/2025 advised decreasing the Omeprazole dose to 20 mg daily due to risks associated with long-term use, and the physician agreed to this recommendation on 12/10/2025. However, review of the medication administration record showed that the resident continued to receive the higher 40 mg dose, indicating the physician-approved pharmacy recommendation was not implemented. Interviews with nursing staff and administration revealed that the process for updating medication orders based on pharmacy recommendations involved the DON and ADON, who were responsible for reviewing, processing, and entering new orders once approved by the physician. Despite this established process, the recommended change was not made, and staff were unable to explain why the order was not updated. The facility's policy on handling unnecessary medications or pharmacy recommendations was requested but not provided during the survey. The administrator acknowledged responsibility for ensuring that pharmacy recommendations, once approved by the physician, are implemented and monitored by nursing administration.
Failure to Secure and Properly Label Medications
Penalty
Summary
Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and properly labeled and dated, as required by professional standards. During observations on two separate occasions, a bottle of normal saline, a bottle of wound cleanser spray, a tube of zinc oxide protectant, and two tubes of zinc oxide silicone cream were found in a mauve basin on top of a resident's personal refrigerator in her room. These items, used for wound care and as barrier creams, were not secured in the medication cart as per facility policy. Interviews with the RN, Administrator, and DON confirmed that these medications should not have been left in the resident's room and should have been stored securely with appropriate labeling. The resident involved had chronic kidney disease, high blood pressure, bipolar disorder, moderate cognitive impairment, impaired vision, and was dependent on staff for several activities of daily living. Her care plan required medications to be provided as ordered, and her medication orders included wound care and barrier cream applications. Facility policy specified that medications and biologicals must be stored safely and securely, accessible only to authorized personnel. The failure to follow these procedures was confirmed through staff interviews and review of facility policy.
Failure to Maintain and Coordinate Required Hospice Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, the facility did not obtain or maintain essential hospice documentation, including the Texas Medicaid Hospice Program Individual Election/Cancellation/Update (Form 3071), Physician Certification of Terminal Illness (Form 3074), Hospice Nurses' Notes, and Hospice Physician Orders. Interviews with the hospice case manager, ADON, DON, and administrator confirmed that these documents were not present in the resident's hospice binder, and there was a lack of verification to ensure the required documents were provided and maintained. The facility's own policy required these documents to be part of the clinical record, but the DON admitted she had not checked the hospice binders for completeness. The resident involved was an older male with chronic obstructive pulmonary disease and cancer, who was cognitively intact and required varying levels of assistance with activities of daily living. Although the resident had an order for hospice services and a care plan indicating hospice needs, the MDS assessment did not reflect hospice services, and the necessary hospice documentation was missing from the records. Staff interviews revealed uncertainty and lack of follow-through regarding responsibility for ensuring hospice documentation was complete and up to date, resulting in a failure to coordinate and communicate the resident's hospice care needs.
Misappropriation of Resident Medication by Staff
Penalty
Summary
A certified medication aide (CMA) at the facility was implicated in the misappropriation of a resident's medication, specifically Ondansetron, which is prescribed to prevent nausea and vomiting. The resident involved was an elderly female with severe cognitive impairment, contractures, dysphagia, and dementia, requiring extensive assistance with activities of daily living. Her care plan included monitoring for symptoms related to her medications, and she had an as-needed order for Ondansetron. The incident came to light when a community member, who was reportedly the CMA's pregnant roommate, provided the facility with a photograph of the resident's blister pack of Ondansetron at her home, as well as screenshots of text messages suggesting the CMA was involved in drug diversion. The text messages indicated the CMA was seeking to obtain and distribute controlled substances, and the community member claimed the CMA had taken the resident's medication for her own use. The facility's investigation confirmed that the blister pack belonged to the resident, and the CMA was confronted with the evidence. Interviews with facility leadership confirmed that the act of removing resident medications from the facility constituted drug diversion and was against facility policy. The Director of Nursing and Administrator both acknowledged that such actions placed the resident at risk for not receiving necessary medication. The facility's policies on medication diversion and abuse required prompt reporting and investigation of such incidents, and the documentation confirmed that the misappropriation of the resident's property had occurred.
Failure to Protect Resident from Abuse and Neglect
Penalty
Summary
The facility failed to protect a resident from abuse and neglect, as evidenced by an incident involving multiple staff members who held the resident down to provide incontinent care against her will. The resident, who has a history of trauma and moderate cognitive impairment, was screaming and yelling for the staff to stop during the incident. Despite her protests, the staff continued to provide care, which the resident perceived as abusive. The resident later reported the incident, describing physical pain and emotional distress, although no physical injuries were observed during subsequent assessments. The incident occurred when a CNA and several student nursing assistants attempted to change the resident, who was incontinent. The staff involved reported that the resident became combative, yelling and attempting to hit and kick them. Despite the resident's resistance and verbal refusal, the staff proceeded with the care, believing they were required to change her due to instructions from charge nurses. The staff members acknowledged that holding a resident down against their will could be considered abuse, yet they felt compelled to continue due to perceived job expectations. Interviews with staff revealed a lack of adherence to the facility's policies on abuse, behavioral management, and restraint. The staff involved did not follow the protocol of stopping care when a resident refuses or becomes combative, nor did they report the incident to a charge nurse as required. The facility's Director of Nursing (DON) confirmed that the staff should have ceased care and respected the resident's right to refuse, highlighting a significant lapse in following established procedures designed to protect residents' rights and well-being.
Removal Plan
- Resident #30 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted. DON completed a skin assessment and pain assessment with no negative findings.
- The DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on following topics: Abuse and Neglect, Behavioral management policy, and Restraint Policy. The administrator will be in-serviced by the Area Director of Operations.
- The 4 staff members were in-serviced 1:1 by the DON and ADON on Abuse and Neglect, Behavioral management policy, and Restraint Policy.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on the following topics: Abuse and Neglect, Behavioral management policy, and Restraint Policy. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment.
Failure in Trauma-Informed Care for Residents
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to residents who are trauma survivors, leading to deficiencies in the care of three residents. Resident #30, who has a history of being kidnapped, raped, and almost murdered, was subjected to being held down and changed against her will by staff members, despite her screaming and yelling for them to stop. This incident was not documented in her care plan, and her potential triggers for re-traumatization were not assessed or documented. Staff members involved in the incident reported feeling pressured to change the resident despite her refusal, due to instructions from the Director of Nursing (DON) that she needed to be changed twice a shift. Resident #4, who has a diagnosis of PTSD, did not have her history of trauma or potential triggers for re-traumatization reflected in her care plan. The facility's social history assessment failed to document her PTSD diagnosis, and her comprehensive care plan did not address her trauma history. Resident #4 reported a history of being molested and forced to consume drugs and alcohol by a family member, which was known to the facility staff but not adequately documented or addressed in her care plan. Resident #2, who also has a diagnosis of PTSD, had her trauma history inadequately documented. Her care plan mentioned PTSD but did not include specific triggers or interventions to prevent re-traumatization. The social worker responsible for assessing trauma history did not document her reported history of abuse by a family member. The facility's failure to properly assess and document the trauma histories and potential triggers for these residents resulted in a lack of appropriate, individualized care, increasing the risk of re-traumatization and psychological distress.
Removal Plan
- Resident numbers #2, #4, and #30 were assessed for emotional distress by the DON. A trauma informed care assessment was completed for each resident by the DON. No additional emotional distress was noted for each resident. DON updated care plans for resident #2, #4 and #30. DON documented trauma informed care interventions with identified triggers and assistance with avoidance on Care Plan and Kardex. Residents #2, #4, and #30 are all receiving psych services. Residents #2, #4, and #30 were involved in setting interventions to reduce re-traumatization.
- The DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on following topics below. The administrator will be in-serviced prior to returning to work by the Area Director of Operations.
- Trauma Informed Care Policy- all residents with a history of trauma or a diagnosis of PTSD will be assessed for potential triggers and have their plan of care modified accordingly.
- Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction.
- Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately.
- Restraint Policy- holding a resident against their will to provide care is considered a restraint.
- The 4 staff members were in-serviced 1:1 by the DON and ADON on the following topics below.
- ADO, DON, and ADON attempted to communicate with the 4 staff members via text and phone call. 2 of the 4 staff members verbally self-termed, 1 staff member was a no call no show for their shift and is being termed and the 4th staff member is PRN and has not responded to text messages or phone calls. Images of the in-services have been texted to her and if she is to return to work, she will be in-serviced by DON or ADON prior to the start of her shift.
- Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction.
- Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care later or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately.
- Restraint Policy- holding a resident against their will to provide care is considered a restraint.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced regarding the following topics below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment.
- Abuse and Neglect to include not to hold a resident down while providing care at any time. If a resident is yelling stop, the staff members will stop and notify the charge nurse, DON, or Administrator for assistance and further direction.
- Behavioral management policy- Explain care to be provided prior to providing the care. If the resident refuses care or becomes combative with care, stop attempting to perform the care being resisted, ensure the resident's safety allow the resident to calm down. Attempt the care at a later time or with different staff. Continued combativeness with care should be reported to the Charge nurse, Administrator and/or DON immediately.
- Restraint Policy- holding a resident against their will to provide care is considered a restraint.
- All clinical staff will be in-serviced regarding the following topic below by the ADO and Regional Compliance Nurse, DON, and ADON. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-service on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment.
- Trauma Informed Care - Definition of and locating triggers/interventions on Care Plan or Kardex.
Resident Burned Due to Hot Coffee Spill
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards, specifically related to the preparation and serving of hot coffee, which led to a second-degree burn for one resident. The incident involved a resident with severe cognitive impairment and Parkinson's disease, who spilled hot coffee on herself, resulting in burns to her right upper thigh and lower abdomen. The resident's comprehensive care plan, which was completed post-incident, indicated that she was at risk for burns due to her impaired cognition and physical limitations. The deficiency occurred because the facility did not adhere to its policy and procedure for preparing and serving coffee at a safe temperature. On the day of the incident, the coffee served to the resident was at a temperature of 158 degrees Fahrenheit, which exceeded the facility's guideline of serving coffee at or below 140 degrees Fahrenheit. This oversight in following the established coffee preparation process directly contributed to the resident's injury. The facility's failure to implement and monitor the necessary interventions for residents at risk of burns from hot liquids was evident. Despite having a process in place, the staff did not follow the required steps to ensure the coffee was cooled to a safe temperature before serving. This lapse in procedure and supervision placed the resident at an increased risk for serious burn injuries while consuming hot liquids.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Several deficiencies were noted, including improper labeling and dating of food items, incorrect use of hair restraints by kitchen staff, and unsanitary conditions of kitchen equipment. Specifically, ice scoops were found stored uncovered on top of the ice machine, a juice machine spigot was observed with a red/orange gooey substance, and a can opener blade was found with a thick black substance. Additionally, a bag of opened tortilla chips was found unlabeled and undated in the dry storage room. Interviews with staff revealed a lack of compliance with hygiene protocols. Dietary Aide R admitted that her hairnet did not cover her entire head, acknowledging the risk of cross-contamination and foodborne illness. Dietary Manager TT was observed touching her nose and then handling food without washing her hands, which she admitted could lead to cross-contamination. Staff members, including Dietary Aide H and [NAME] VV, confirmed that they were responsible for ensuring proper storage and cleanliness of kitchen equipment, but these practices were not consistently followed. The facility's policies on equipment sanitation, infection control, and food storage were reviewed, highlighting the importance of personal cleanliness and proper food handling procedures. Despite these policies, the facility's practices did not align with the guidelines, as evidenced by the observations and staff interviews. The Area Director of Operations and the Dietician both emphasized the importance of these standards, yet the deficiencies observed indicate a failure to implement and monitor these practices effectively.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, impacting several residents and a linen cart. Observations revealed that a CNA did not perform proper hand hygiene while providing incontinent care to a resident with severe intellectual disabilities and other health issues. The CNA changed gloves without washing hands and did not clean the resident's peri area, potentially spreading infection. Another CNA entered a resident's room without wearing the required PPE, despite the resident being on enhanced barrier precautions due to wounds. A Licensed Vocational Nurse (LVN) also failed to perform hand hygiene after checking a resident's blood sugar and administering insulin. This resident had multiple health conditions, including diabetes and cerebral palsy. The LVN admitted to forgetting the hand hygiene step, which could lead to infection. Additionally, another CNA did not change gloves or perform hand hygiene during incontinent care for a resident with ovarian cancer and COPD, and improperly handled wipes, risking cross-contamination. The Director of Nursing (DON) and a Nursing Assistant (NA) did not wear appropriate PPE when entering a resident's room or handling dirty linen, despite the resident being on enhanced barrier precautions. Furthermore, a laundry aide transported clean clothing on an uncovered cart, exposing it to potential contamination. These practices were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene and proper use of PPE to prevent the spread of infections.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, impacting their quality of life. One resident, a female with major depressive disorder, anxiety, morbid obesity, and heart failure, was called 'big girl' by the Administrator, which upset her and led to emotional distress. This resident also experienced a situation where CNAs and a medication aide told her that washing her hair was too time-consuming, which made her feel unwanted and neglected. Another resident, diagnosed with cerebrovascular disease, Alzheimer's, and major depressive disorder, was reportedly told to 'shut up' by a CNA. This incident was reported by the resident's family member, who was informed by another resident. The family member also noted that several residents had similar complaints about the same CNA. A third resident, with rhabdomyolysis, dementia, and muscle weakness, reported feeling pressured by a CNA to clean herself. The CNA allegedly left the resident with her pants down, which the resident found disrespectful. This incident was reported during a safe survey, and the resident expressed feeling that the CNA was trying to force her opinion on her.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider and act upon the grievances and recommendations of the resident council concerning issues of resident care and life. Specifically, the facility did not document efforts to resolve concerns raised during resident council meetings from May to October 2024. The primary issue raised consistently in these meetings was the untimely response to call lights, particularly during the night shift. Despite these repeated concerns, there was no documentation of grievances filed or actions taken to address the issue. During a confidential group interview with 16 residents, it was revealed that call lights were often turned off by staff with promises to return, which were not fulfilled. The residents had communicated these concerns to the Administrator and other staff, but the issue remained unresolved. The facility's policy on grievances, which mandates prompt efforts to resolve grievances and requires the Administrator or their designee to oversee the grievance process, was not followed. The facility had experienced turnover in the Administrator position, with 4-5 interim administrators, and the current Administrator was on vacation at the time of the survey.
Unqualified Activity Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The Activity Director, who was hired on 10/14/2024, began her role on 10/17/2024 without the necessary certification. During interviews, the Activity Director acknowledged her lack of certification and mentioned that the Administrator had given her six months to obtain it. She also noted that other staff members, including Medical Records, the DON, and ADON, were assisting her in scheduling activities, but they were not certified either. The Activity Director emphasized the importance of certification to understand the residents' needs and the scope of activities she could provide. Further interviews revealed that the Activity Director was not being monitored by anyone, and the ADO confirmed that the Activity Director was expected to be certified as per state requirements. The ADO also highlighted the importance of certification for the Activity Director to perform her duties effectively. Despite a request for the facility's policy on activities from the Regional Compliance Nurse, it was not provided by the time of the survey exit.
Failure to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for all 16 residents reviewed for food and nutrition services. During a confidential resident group meeting, all 16 residents reported that the food was bland and consistently cold. On 10/29/24, during an observation and interview, the lunch tray sampled by the Dietary Manager and four surveyors included buttered noodles, carrots, and pork shank, all of which were found to be lukewarm or cool. Additionally, the honey roll had a vinegary taste, which was noted by the Dietary Manager. Interviews revealed that the Dietary Manager had not received any complaints about the food being cold or tasting different, although he acknowledged that there had been complaints in the past. The Regional Compliance Nurse confirmed there was no policy regarding the palatability of meals. The Area Director of Operations expressed an expectation that meals should be palatable in terms of temperature and taste, and noted that the dietary department was responsible for ensuring this. The deficiency could potentially lead to decreased food intake and unwanted weight loss among residents.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for several residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. For one resident, the facility did not develop or implement a care plan for in and out self-catheterization, despite the resident performing this procedure herself. The Director of Nursing (DON) acknowledged the oversight and recognized the risk of urinary tract infections due to the lack of a care plan detailing the catheter size, equipment needed, and timing. Another resident's care plan did not reflect her history of trauma, which she had reported to the facility staff. Interviews with staff members revealed a lack of awareness and access to information regarding the resident's traumatic history, which is crucial to prevent re-traumatization during care. The DON and Social Worker both acknowledged the importance of including trauma history in the care plan to understand and manage the resident's behaviors effectively. Additionally, the facility did not ensure that a resident's care plan included treatment for wounds requiring specific care regimens. The care plan lacked details on the treatment for wounds on the resident's right medial thigh and right distal medial calf, despite having orders for specific wound care. Furthermore, another resident's care plan failed to reflect a diagnosis of Diabetes Mellitus, even though the resident was receiving insulin and other medications for diabetes management. The MDS Coordinator admitted that these omissions were oversights, emphasizing the importance of updating care plans to accurately reflect residents' current medical conditions and treatment needs.
Failure to Log and Reconcile Controlled Medications
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which led to a deficiency in maintaining accurate records and reconciliation of these medications. During an observation, unlogged medications were found in the controlled medications storage area awaiting disposal. These included various forms of Morphine and Diazepam, as well as Hydrocodone/APAP. The Director of Nursing (DON) admitted that the medication log was not up to date and acknowledged the risk of medications going missing due to this oversight. Interviews with the facility's pharmacist and the Regional Director of Operations revealed that the DON was responsible for overseeing expired or discontinued medications. The process required both the nurse and the DON to sign off on the narcotic sheet, log the medications on the destruction sheet, and keep them under double lock until destruction. However, the DON did not follow this policy, leading to a lack of proper logging and potential risks associated with unaccounted medications. The facility's policy mandates that controlled substances be stored securely and logged accurately, which was not adhered to in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards, as observed in two medication carts and one medication room refrigerator. Specifically, the Treatment Nurse did not secure the facility's only treatment cart, leaving it unlocked and accessible to residents. This oversight was acknowledged by the Treatment Nurse, who admitted to rushing off and leaving the cart unsecured. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both emphasized the importance of locking medication carts to prevent unauthorized access and potential harm to residents. Additionally, several medications on Hall C's nurse cart were found to be open and undated, including insulin and inhalers for multiple residents. The lack of dating on these medications was confirmed by LVN B, who stated that all medications should be dated when opened to ensure their effectiveness. The ADON and DON both expressed that it was the responsibility of the nurse or medication aide who opened the medications to date them, and that regular audits should be conducted to check for expired medications. Furthermore, an expired medication was found in the medication room refrigerator, specifically Diazepam suppositories that had expired the previous month. The Regional Director of Operations stated that no undated or expired medications should be present on medication carts or in the refrigerator. The facility's policies on medication storage and insulin pen use were reviewed, indicating that medications should be dated when opened and removed after expiration to maintain their effectiveness.
Failure to Provide Nectar-Thickened Liquids
Penalty
Summary
The facility failed to provide liquids consistent with the needs of two residents, both of whom required nectar-thickened liquids due to swallowing difficulties. Resident #49, a female with Angelman syndrome, severe intellectual disabilities, and other conditions, was observed to have been served tea that was not nectar-thickened during her lunch meal. The CNA responsible for serving the meal did not notice the inconsistency, and the dietary aide admitted to 'eyeballing' the thickness rather than following the prescribed method, which could lead to choking. Similarly, Resident #44, a female with Parkinson's Disease and dementia, was also served liquids that were not of the required nectar consistency. The LVN initially failed to notice the inconsistency on the resident's tray card, and it was only upon rechecking that the error was identified. The dietary manager acknowledged that the kitchen was out of pre-made nectar-thick tea and that the dietary aide should have followed the directions to prepare the correct consistency. Interviews with various staff members, including the ADON, DON, and the Regional Director of Operations, confirmed that the residents were at risk for aspiration and choking due to the failure to provide the correct liquid consistency. The facility's policy on thickened liquids, which mandates preparation as per physician orders, was not adhered to, leading to the deficiency.
Failure to Provide Prescribed Fortified Diet
Penalty
Summary
The facility failed to ensure that a resident received a therapeutic diet as prescribed by the attending physician. Specifically, Resident #49, who had a history of Angelman syndrome, protein-calorie malnutrition, severe intellectual disabilities, and other conditions, was not provided with fortified pudding as ordered. The resident's care plan indicated a risk for malnutrition, and the physician's orders included a regular diet with pureed texture, nectar consistency, double portion, and fortified pudding once a day for nutrition. However, during an observation, it was noted that the pudding provided to the resident was not fortified as required. Interviews with staff revealed a lack of awareness and adherence to the dietary orders. An LVN assisting the resident was unsure if the pudding was fortified, and a dietary aide admitted to not fortifying the pudding, believing the resident did not need it. The Dietary Manager was unaware of the issue until informed by the surveyor and acknowledged the importance of following the fortified food recipe. The ADON and DON both emphasized the necessity of following dietary orders to support the resident's nutritional needs, especially given the resident's low weight. The Regional Director of Operations also highlighted the importance of providing the correct diet to prevent weight loss.
Failure to Follow Smoking Policy
Penalty
Summary
The facility failed to adhere to its established smoking policy, specifically concerning the use of a smoking apron for a resident and the presence of combustible materials in the designated smoking area. A resident, who was assessed to require direct supervision and a fire-resistant smoking apron while smoking, was observed without the apron during a supervised smoking break. Additionally, a propane grill with an attached propane tank was found in the smoking area, with a trashcan for cigarette butts in close proximity, which violated the facility's smoking policy. Interviews revealed that the staff member supervising the smoking break was unaware of the requirement for the resident to wear a smoking apron and did not know where to find such information. The Assistant Director of Nursing (ADO) and the Director of Nursing (DON) both expressed expectations that staff should ensure smoking assessments are completed and communicated, and that smoking interventions are implemented to maintain safety. The facility's smoking policy, revised in 2017, mandates supervision for residents classified as unsafe smokers and prohibits smoking in areas with flammable materials, which was not adhered to in this instance.
Inaccurate MDS Assessment for Resident's Catheterization
Penalty
Summary
The facility failed to ensure that the MDS assessment for a resident accurately reflected her use of in and out self-catheterization. The resident, a female with a history of lumbar spina bifida, hemiplegia, paraplegia, and urinary tract infection, was documented to have a neurogenic bladder requiring daily in and out catheterization. However, the Quarterly MDS assessment did not indicate the use of any catheterization, despite documentation of catheter urine output in the resident's records and a progress note by the NP confirming the procedure. The MDS Coordinator did not code the resident's self-catheterization on the MDS, citing a lack of proof of catheter use within the look-back period. The Director of Nursing confirmed the resident's use of in and out catheters since January 2023. The absence of a policy for MDS accuracy and reliance on the RAI manual was noted by the Regional Compliance Nurse. The ADO emphasized the importance of accurate MDS coding for determining the resident's level of care and ensuring appropriate care planning, highlighting a lack of communication between the DON, ADON, and MDS nurse.
Failure to Follow Wound Care Orders and Report Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. For Resident #42, the facility did not ensure that LVN A and LVN OO followed physician orders for wound care on the resident's right distal medial calf. The wound care orders specified cleansing the area with normal saline, applying santyl ointment, covering with alginate calcium dressing, and securing with island gauze on specific days. However, the wound dressing was not changed over the weekend, as observed on 10/28/24, with the dressing dated 10/25/24. Both LVN A and LVN OO admitted to not performing the wound care due to being busy and accidentally marking the task as completed, potentially putting the resident at risk for infection. For Resident #51, the facility failed to ensure that CNA N and Student NA Z reported to the charge nurse after the resident had an unwitnessed fall. The resident, who had a history of falls and was at high risk, was found on the floor by CNA N and Student NA Z during shift change. Despite the resident's request not to report the fall, the CNAs did not inform the charge nurse, delaying the assessment for potential injuries. The resident later reported the fall to the MDS Coordinator, who then informed the Administrator and DON. The failure to report the fall immediately could have delayed necessary medical assessments and interventions. The facility's policies on physician orders and falls did not adequately address the reporting of falls, contributing to the deficiencies observed. The DON and Regional Compliance Nurse emphasized the importance of following wound care orders and reporting falls immediately to ensure residents' safety and proper care. The lack of adherence to these protocols resulted in potential risks to the residents' health and safety.
Failure to Provide Supplies and Education for Self-Catheterization
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident who was incontinent of the bladder and had an indwelling urinary catheter. The resident, a female with a history of lumbar spina bifida, hemiplegia, paraplegia, and urinary tract infection, was not provided with the necessary supplies to perform in and out self-catheterization. Despite having a neurogenic bladder and performing self-catheterization, the resident's care plan and order summary did not reflect this need, and she was only provided with Foley catheters. Observations and interviews revealed that the resident did not have access to essential supplies such as gloves, hand sanitizer, and cleansing wipes, which are crucial for maintaining hygiene during catheterization. The resident reported that she had not received any teaching from the nursing staff on how to properly perform the procedure. The Director of Nursing (DON) acknowledged that the resident should have had an order for self-catheterization and that the necessary supplies should have been within her reach. However, the supplies were not available, and the resident's storage container was out of reach. Interviews with the nursing staff indicated a lack of awareness and education regarding the resident's needs for self-catheterization. The Licensed Vocational Nurse (LVN) and Treatment Nurse admitted to not providing the necessary education or checking the resident's room for supplies. The DON and Assistant Director of Nursing (ADO) recognized the importance of providing the resident with the proper tools and education to prevent urinary tract infections, but these measures were not implemented, leading to the deficiency.
Inadequate Competency in Infection Control and Incontinent Care
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA K, demonstrated the necessary competencies in infection control and providing incontinent care. This deficiency was observed during an incident involving a resident who was admitted with ovarian cancer and chronic obstructive pulmonary disease. The resident's care plan required regular checks and assistance with toileting due to bladder and bowel incontinence. During an observation, CNA K did not perform proper hand hygiene, used dirty gloves to handle clean items, and failed to adequately clean the resident, leaving stool residue. CNA K admitted to not being properly trained or observed by nurse management in performing incontinent care since starting at the facility. She followed practices she learned from other staff, which included improper handling of wipes that could lead to cross-contamination. The CNA also mentioned that her competency check was not adequately completed, as it was left for her to sign without any observation of her skills by management. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed that competencies were supposed to be completed upon hire and annually, but there was a lack of proper documentation and observation. The ADON admitted to not dating the competency checks and not observing CNA K's skills, which was crucial to ensure correct care practices. The facility's policy for staff competencies was requested but not provided by the Regional Compliance Nurse upon exit.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a rate of 5.26 percent due to two errors in insulin administration. These errors involved two residents who were reviewed for medication administration. The first resident, a female with diagnoses including congestive heart failure, diabetes mellitus type 2, schizophrenia, and COPD, did not receive the correct insulin administration. During an observation, LVN B administered 6 units of Humalog insulin without priming the pen, which is a necessary step to ensure the pen is functioning correctly. The second resident, also a female with diagnoses including cerebral palsy, diabetes mellitus type 2, PTSD, depression, and anxiety, experienced a similar error. LVN A administered 2 units of Novolog insulin without priming the pen. LVN A admitted to not being aware of the need to prime the insulin pen before administration, which is crucial for ensuring the correct dose is delivered. Interviews with the ADON and DON revealed a lack of awareness and training regarding the priming of insulin pens. The facility's policy on insulin pen use, which includes steps for priming the pen, was not followed. This oversight in training and adherence to policy contributed to the medication errors observed during the survey.
Failure to Provide Timely Laboratory Services for Residents
Penalty
Summary
The facility failed to provide timely laboratory services for two residents, leading to deficiencies in their care. Resident #9, who has type 2 diabetes mellitus with diabetic neuropathy, did not receive a physician-ordered A1C test, which measures average blood sugar levels over three months. The last A1C test for Resident #9 was conducted on 07/09/24, and the subsequent test due in October was missed. The Director of Nursing (DON) was unaware of the missed test until it was pointed out by a state surveyor. The DON acknowledged the oversight and mentioned that the resident's hospitalization in October contributed to the lapse, as the discharge paperwork was not thoroughly reviewed to ensure the A1C test was conducted. Resident #49, a female with multiple diagnoses including Angelman syndrome and severe intellectual disabilities, did not have her potassium level re-drawn as ordered by the physician on 07/23/24. The initial lab result on 07/15/24 indicated a potassium level of 5.3, prompting a re-draw request. However, the re-draw was not performed, and the DON admitted to a breakdown in the lab system, which was addressed in August 2024. The DON and Assistant Director of Nursing (ADON) were unaware of the missed lab order until the surveyor's intervention, and the facility's process for handling lab orders was not followed, leading to the oversight. The facility's policy on physician's orders outlines the process for receiving, documenting, and executing orders, but it appears there was a failure in adhering to this policy. The DON stated that there was no specific policy on labs, but they followed the physician order policy. The Regional Director of Operations emphasized the importance of drawing labs as ordered for resident health, but the facility's oversight in these cases resulted in missed lab tests for both residents, potentially impacting their health management.
Resident Lacks Access to Call Light System
Penalty
Summary
The facility failed to ensure that a resident had access to a call light system, which is essential for requesting staff assistance. Observations revealed that the resident, who was cognitively impaired and required total assistance with daily activities, did not have a call light within reach. The resident's care plan specifically indicated the need for a call light to be accessible, yet during multiple observations, no call light was present on the resident's side of the room. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Regional Director of Operations, confirmed the absence of a call light for the resident. The staff acknowledged the importance of having a call light within reach to prevent delays in assistance and potential risks such as falls. Despite the facility's policy requiring call lights to be accessible, no policy document was provided upon request.
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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