The Brazos Of Waco
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 2430 Market Place Drive, Waco, Texas 76711
- CMS Provider Number
- 676409
- Inspections on file
- 40
- Latest survey
- January 23, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at The Brazos Of Waco during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple pressure ulcers, and complex wound care orders for the coccyx, sacrum, left foot, and left hip had wound treatments that were not signed off in the electronic MAR by two RNs on multiple shifts. Physician orders required specific wound care regimens with zinc oxide, Dakins solution, normal saline, alginate calcium, and dressings at prescribed frequencies, but MAR review showed missing signatures for several scheduled treatments. The DON and ADM stated that unsigned MAR entries indicate treatments were not completed and that staff are expected to document in Matrix when care is provided. One RN reported that he performed all wound treatments but failed to document them due to other nursing duties, while the wound care doctor and the resident’s responsible party described the resident’s serious condition and frequent hospitalizations.
A resident with a history of infective endocarditis and on hemodialysis was given multiple doses of Valacyclovir after hospital discharge instructions had ordered the medication to be stopped. An agency nurse failed to discontinue the drug in the electronic medical record, leading to the resident developing confusion and metabolic encephalopathy due to Valacyclovir toxicity. The error was only discovered after the resident's condition deteriorated and required rehospitalization.
A deficiency was cited due to the facility not ensuring an area was free from accident hazards and not providing adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was lacking, but does not specify particular incidents or individuals involved.
Staff did not immediately inform a resident, the resident's doctor, and a family member about situations such as injury, decline, or room changes that affected the resident, as required. This deficiency was identified through review of facility practices and records.
A resident with multiple medical conditions was denied re-admission to the facility after a hospital stay, without the required written discharge notice or documentation. Staff interviews confirmed that the standard 30-day notice and discharge planning process was not followed, and the resident's chart lacked the necessary discharge paperwork, contrary to facility policy.
A resident with significant mental health diagnoses did not have PASARR Level II recommendations incorporated into their assessment and care planning in a timely manner. The facility failed to submit the required NFSS request within the designated timeframe after an IDT meeting, and confusion among staff regarding responsibility for the process led to delays and an initial denial before eventual approval. Communication lapses and lack of awareness of the PASARR process contributed to the deficiency.
A resident with a history of heart failure experienced a significant weight gain and symptoms of shortness of breath, but nursing staff did not notify the CHF clinic or provider as required by orders. Although daily weights and symptoms were documented, there was no evidence of timely communication, resulting in delayed care and the need for IV Lasix when the resident was eventually seen at the clinic. Staff interviews confirmed awareness of the notification requirement but revealed it was not followed.
A resident with CHF experienced a significant weight gain and symptoms of shortness of breath, but staff failed to notify the CHF clinic as required by provider orders. Despite daily weights showing abnormal increases and care plan interventions for monitoring and notification, no documentation or direct communication to the CHF clinic occurred, resulting in delayed care and the need for IV Lasix administration.
A resident with COPD and CHF was sent to medical appointments with empty oxygen tanks, leading to shortness of breath and anxiety. Despite previous grievances and care-plan meetings, the facility failed to ensure the resident's oxygen needs were met, resulting in critically low oxygen levels during appointments. Staff were inadequately trained on new oxygen regulators, contributing to the deficiency.
A facility failed to implement a comprehensive care plan for a resident with COPD and CHF, neglecting to address her need for oxygen, monitoring for shortness of breath, and specialty medical appointments. The resident experienced issues with oxygen supply during medical visits, leading to confusion and anxiety. Staff interviews revealed a lack of coordination in updating the care plan, potentially affecting the resident's care.
The facility failed to weigh three residents according to physician orders, despite their medical conditions requiring regular monitoring. A resident with congestive heart failure and diabetes was weighed inconsistently over a two-week period, another with severe cognitive impairment and kidney failure was weighed only once in three weeks, and a third with diabetes and obesity was weighed four times in two months. The DON acknowledged the importance of following orders, but the facility's policy did not emphasize this, leading to the oversight.
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in oxygen therapy management. A resident was using an oxygen concentrator without a physician's order or an 'Oxygen in Use' sign. Another resident was found with an empty oxygen tank while eating lunch, and their oxygen tubing was not bagged. A third resident had their nasal cannula tubing disconnected from the concentrator, and the water cannister was empty.
The facility failed to maintain an effective infection control program, as evidenced by two incidents where staff did not adhere to Enhanced Barrier Precautions (EBP). A CNA did not wear required PPE while caring for a resident with a wound on EBP, and an LVN used a pulse oximeter on a resident on EBP for catheter use without sanitizing it before placing it back in her pocket. Both staff members had received training on EBP, but failed to follow protocols, potentially risking the spread of infections.
The facility failed to include critical medications in the care plans of four residents, including anticoagulants, opioids, and antiplatelets. This oversight involved residents with severe cognitive impairments and various medical conditions, potentially placing them at risk for unmet care needs. Staff interviews revealed a lack of clarity and responsibility in updating care plans.
The facility failed to provide necessary bathing services to several residents who were dependent on staff for assistance. Despite being scheduled for regular showers or bed baths, these residents did not receive the care needed to maintain personal hygiene. Interviews and record reviews revealed inconsistencies in documentation and challenges in staffing, contributing to the deficiency.
The facility failed to conduct weekly skin assessments for three residents at risk of pressure ulcers, as ordered by physicians. A resident with paraplegia and a stage 3 pressure ulcer, another with a history of pressure ulcers, and a third with severely impaired cognition did not receive the necessary assessments. Staff interviews revealed that reliance on agency nurses contributed to the oversight, and the facility's policy on skin assessments was not provided.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their comprehensive assessments. A resident's quarterly MDS assessment did not reflect hospice services, while two other residents' assessments inaccurately documented their medication regimens. These errors could result in inadequate care planning and service provision. Interviews with the MDS nurse and DON highlighted a lapse in the facility's assessment processes.
The facility failed to properly label and secure drugs and biologicals, with loose pills found in medication carts and personal items improperly stored. Staff interviews revealed inconsistencies in handling these issues, with some staff unaware of specific policies. The DON acknowledged the risks of theft and contamination but was unsure of specific policies regarding loose pills.
A resident with multiple medical conditions was improperly transferred using a mechanical lift, leading to a fall and subsequent fracture. The CNAs involved failed to position the resident correctly in the lift sling and did not ensure adequate space for the lift's operation. The incident was captured on video, showing the resident tilting and falling due to inadequate supervision and improper use of the lift.
The facility failed to ensure timely meal service for five residents, leading to feelings of hunger, agitation, and diminished self-worth. Observations and staff interviews confirmed that meals were consistently served late, sometimes by an hour, despite the facility's nutrition policies specifying meal times. The Administrator did not acknowledge the issue, and the deficiency persisted, affecting residents' quality of life.
The facility failed to provide special eating equipment and utensils for four residents, leading to difficulties in eating and potential nutritional deficiencies. Observations revealed missing adaptive utensils for residents with specific needs, and interviews with staff confirmed the importance of these devices for adequate nutrition and dignity.
The facility failed to maintain an infection prevention and control program, leading to improper blood sugar checks and insulin administration for two residents. An LVN reused alcohol pads and did not follow proper cleaning procedures, despite being trained otherwise. The DON confirmed the correct procedures were not followed, posing a risk of infection.
A resident with severe cognitive impairment was transferred to another facility without the responsible party's (RP) approval. The RP had initially agreed to send referral packets but requested to be contacted before any transfer. Due to miscommunication and assumptions between the social worker and admission coordinator, the transfer occurred without the RP's knowledge or consent.
Incomplete Documentation of Ordered Wound Treatments in MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident with multiple pressure ulcers and complex wound care needs. The resident was an elderly male with diagnoses including essential hypertension, dysphagia, edema, severe cognitive impairment (BIMS score of 3), and multiple pressure ulcers on the left distal medial foot, left lateral foot, right hip, left hip, coccyx, and sacrum related to reduced mobility. Physician orders directed specific wound treatments to the coccyx, sacrum, left distal medial foot, left lateral foot, and left hip, including the use of zinc oxide, Dakins solution, normal saline, alginate calcium, and dressings at prescribed frequencies. Record review of the Medication Administration Record (MAR) showed that on one date, wound treatments ordered three times every shift for the coccyx and sacrum were not signed off by an RN for the 7:00 PM and 11:00 PM times, and daily wound treatments for the left distal medial foot, left lateral foot, and left hip were not signed off for the 7:00 AM–7:00 PM period. On another date, the coccyx and sacrum treatments ordered three times every shift were not signed off by a different RN for the 7:00 PM time. The DON and ADM both stated that the expectation was for nurses to sign off in the electronic MAR (Matrix) once treatments were completed, and that an unsigned MAR entry would indicate the treatment was not completed. In interviews, the wound care doctor reported visiting weekly, debriding the resident’s foot on a mid-month date, and finding exposed bone, after which the resident was sent to the hospital for a higher level of care. The wound care doctor stated the resident had daily wound care treatments and that unsigned treatments on the identified dates would not have made the wounds worse, and he was not aware of any missed treatments. The resident’s responsible party stated the resident had been very sick, in and out of the hospital, and was sent out again for a change in condition, and she did not blame anyone for the resident’s health decline. RN A stated he provided all wound treatments on the identified date but did not sign them off because he was assisting with other nursing duties afterward, and acknowledged it was expected to sign off when treatments were completed and that lack of a signature would indicate the treatment was not done. RN B’s interview was initiated but not completed in the report excerpt. These findings demonstrate incomplete and inaccurate documentation of ordered wound treatments in the resident’s medical record.
Medication Reconciliation Failure Leads to Administration of Discontinued Drug
Penalty
Summary
A significant medication error occurred when a resident, who had recently returned from a hospital stay, was administered five doses of Valacyclovir 1000mg after the hospital discharge summary had clearly stated to discontinue the medication. The resident had a history of acute and subacute infective endocarditis and required hemodialysis. Upon readmission, an agency nurse was responsible for entering the resident's medications into the electronic medical record but failed to discontinue Valacyclovir as ordered in the hospital discharge instructions. The medication error was not immediately identified, and the resident received multiple doses of the discontinued medication over two days. The error was discovered only after the resident exhibited confusion, slurred speech, and inability to follow commands, as reported by a family member and confirmed by a bilingual LVN. The resident was subsequently assessed by a nurse practitioner and transferred back to the hospital, where the diagnosis of metabolic encephalopathy due to Valacyclovir toxicity was made. Interviews revealed that the agency nurse responsible for the error was unfamiliar with the electronic medical record system and did not seek assistance or clarification. The facility's medication reconciliation policy required review of discharge medication profiles with readmission orders, but this process was not properly followed, resulting in the administration of a discontinued medication and subsequent harm to the resident.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, and supervision was insufficient to prevent potential or actual accidents. Specific actions or omissions by staff or management that led to this deficiency are not detailed in the report, nor are any particular residents or incidents described.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes the failure to provide prompt notification to all required parties when significant events impacting the resident occurred.
Failure to Provide Required Discharge Notice and Documentation
Penalty
Summary
The facility failed to permit a resident to remain in the facility and did not document the reason or provide notice of discharge in the resident's medical record. The resident, a male with diagnoses including metabolic encephalopathy, gastric reflux, prostate disease, Parkinson's disease, and cognitive communication deficit, was sent to the emergency room for evaluation after exhibiting out-of-character behavior involving an incident with a staff member. Despite the hospital finding no medical changes and clearing the resident for return, the facility refused to accept him back and did not provide the required written discharge notice to the resident, his representative, or the Long-term Care Ombudsman. Interviews with facility staff confirmed that the normal process is to issue a 30-day discharge notice and assist with safe discharge planning, but this was not followed in the resident's case. The resident's chart did not contain a discharge notice, and discharge paperwork was still in process after the resident was denied re-admission. The facility's own policy requires written notification and documentation of discharge at least 30 days in advance, which was not adhered to in this instance.
Failure to Timely Incorporate PASARR Recommendations and Submit NFSS Request
Penalty
Summary
The facility failed to incorporate recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, the facility did not submit a Nursing Facility Specialized Services (NFSS) request within 20 days of the Interdisciplinary Team (IDT) meeting for a resident with multiple mental health diagnoses, including schizoaffective disorder and major depressive disorder with psychotic features. The care plan identified the need for coordination with mental health services, but the required documentation and timely submission of the NFSS request were not completed as required. The delay was attributed to staff being unaware of the IDT meeting and confusion over responsibility for submitting the NFSS, resulting in the initial request being submitted late and subsequently denied before being resubmitted and accepted. Interviews with facility staff revealed lapses in communication and understanding of the PASARR process. The MDS nurse was on vacation during the IDT meeting and only learned of it later, while the Director of Rehabilitation was unaware of the meeting and did not know how to complete the NFSS form. The administrator acknowledged awareness of the issue but stated it occurred under previous administration. Facility policy requires timely coordination and documentation for PASARR services, but these steps were not followed, leading to a deficiency in ensuring the resident received the necessary specialized services in a timely manner.
Failure to Notify Provider and CHF Clinic of Significant Weight Gain in Resident with Heart Failure
Penalty
Summary
The facility failed to immediately notify a resident's representative and the Congestive Heart Failure (CHF) clinic of significant changes in the resident's physical status, specifically a substantial weight gain, as required by provider orders. The resident, who had diagnoses including acute on chronic heart failure, generalized anxiety disorder, and early-onset Alzheimer's disease, experienced a weight increase of over 13 pounds within a week. Provider orders specified that the CHF clinic should be notified of a weight gain of 2 or more pounds overnight or 3-5 pounds in one week, but there was no documentation that such notification occurred during the period in question. Nursing progress notes and interviews confirmed that although daily weights were recorded and the resident exhibited symptoms such as shortness of breath and low oxygen saturation, the CHF clinic was not informed of these changes. Nursing staff acknowledged awareness of the notification requirement but did not follow through, and there was no evidence of follow-up to ensure the CHF clinic was made aware. The lack of notification resulted in the resident requiring IV Lasix for fluid overload when eventually seen at the CHF clinic. Interviews with the resident's family, the CHF clinic RN supervisor, and the resident's physician all confirmed that the CHF clinic was not notified of the weight gain, which delayed care and led to the need for more intensive intervention. The facility's policy required prompt notification and documentation of changes in condition, but this was not adhered to in this case. The deficiency was identified as Immediate Jeopardy due to the failure to follow provider orders and ensure timely medical evaluation and treatment.
Removal Plan
- The facility activity report and the 24-hour report will be audited by the Director of Nursing/Designee to identify any documentation that indicates changes in resident's condition and notification to provider as ordered.
- The Director of Nursing will be reeducated by the Clinical Consultant on following providers orders to prevent a delay in treatment and change in condition including: prompt notifications documented in residents medical record to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; nursing leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor; shortness of breath; weight gain in residents with Congestive Heart Failure causing shortness of breath.
- Licensed nurses, including PRN nurses, will be reeducated by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; shortness of breath; weight gain in Congestive Heart Failure residents causing shortness of breath. Licensed Nurses, including PRN nurses not receiving this education will receive prior to their next scheduled shift and this will be completed in New Hire orientation.
- Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months.
- The Administrator will oversee the continuation of this plan.
- Ad Hoc QAPI will be held.
- The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
- Monitoring included the following: Record review completed of the facility 24-hour report. Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up.
- Ongoing training will be provided to any oncoming agency, PRN, or new staff.
Failure to Notify CHF Clinic of Significant Weight Gain in Resident
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of congestive heart failure (CHF) received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not notify the CHF clinic of the resident's significant weight gain as required by provider orders. The resident experienced a weight increase of more than 10 pounds within a week, as documented in daily weight records, and exhibited symptoms such as shortness of breath and low oxygen saturation levels. Despite clear physician orders to notify the CHF clinic for weight gains of 2 or more pounds overnight or 3-5 pounds in one week, there was no documentation in the nursing progress notes that such notifications were made during the period of weight gain. Interviews with nursing staff confirmed that although weights were taken and abnormal findings were reported during shift handovers, no direct notification was made to the CHF clinic. The resident's care plan also included interventions to monitor for respiratory distress and to contact the medical provider if noted, but these interventions were not fully implemented as required. The lack of timely notification resulted in the resident requiring IV Lasix administration at the CHF clinic after the significant weight gain and onset of shortness of breath. Family members and clinical staff from the CHF clinic confirmed that they were not informed of the resident's weight changes by the facility, which led to a delay in care. The facility's own policy required prompt notification and documentation of changes in condition, but this was not followed in this case, as confirmed by interviews with the DON, nursing staff, and the resident's physician.
Removal Plan
- The facility activity report and the 24-hour report will be audited by the Director of Nursing/Designee to identify any documentation that indicates changes in resident's condition and notification to provider as ordered.
- The Director of Nursing will be reeducated by the Clinical Consultant on following providers orders to prevent a delay in treatment and change in condition including: prompt notifications documented in residents medical record to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; nursing leadership will validate in clinical morning meeting that any documentation regarding a change of condition has been assessed appropriately and provider has been notified. This will be documented on the Clinical Morning Meeting Agenda during morning meeting by the Director of Nursing/Designee and on the Weekend by the Weekend Supervisor; shortness of breath; weight gain in residents with Congestive Heart Failure causing shortness of breath.
- Licensed nurses, including PRN nurses, will be reeducated by the Director of Nursing/Designee on following provider orders to prevent a delay in treatment and change in condition including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties by the licensed nurse will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered; shortness of breath; weight gain in Congestive Heart Failure residents causing shortness of breath. Licensed Nurses, including PRN nurses not receiving this education will receive prior to their next scheduled shift and this will be completed in New Hire orientation.
- Director of Nursing/Designee will review the Facility Activity Report and 24-hour report in clinical morning meeting to identify any documentation regarding a change in condition and validate the resident has been assessed appropriately and provider notified. The Weekend Supervisor will validate on the weekend. This will continue for 4 weeks, then randomly for 2 additional months.
- The Administrator will oversee the continuation of this plan.
- Ad Hoc QAPI will be held.
- The Medical Director was notified of the Immediate Jeopardy and contents of this plan.
- Monitoring included the following: Record review completed of the facility 24-hour report. Completed by the DON. All residents in the facility were reviewed for any concerns identified and marked for follow up.
- Record review of an in-service titled: Change of Condition monitoring, reviewing clinical documentation and signs & symptoms of CHF exacerbation with proper notification to providers of changes.
- Record review of an additional in-service on prompt notifications to providers, documentation, and validation in clinical morning meetings.
- Record review of in-service titled Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
- Record review of a staff in-service revealed staff were educated on Heart Failure Management- recognizing change of condition in CHF Residents such as weight gain and shortness of breath along with other symptoms.
- Record review of a staff in-service revealed staff were educated on prompt notifications to providers, documentation, notifications to required medical staff of weight changes as ordered, shortness of breath, and weight gain in Congestive Heart Failure residents causing shortness of breath.
- Record Review of training titled: Change of Condition revealed staff were trained on licensed nurses must notify providers of change of condition for orders if necessary to prevent a delay in treatment including: prompt notifications to providers as designated in provider orders; all attempts to notify medical staff and responsible parties will be documented in resident's medical record; notifications to required medical staff of weight changes as ordered.
- Record review of the Adhoc QAPI for F684 revealed the meeting included the ADM, DON, CC, and MD.
- Record Review of a signed statement by the DON revealed notification to the MD regarding Immediate Jeopardy.
- Record review of the new hire orientation packet which included an added section revealed the following: respiratory care all nurses validate resident is receiving oxygen per MD orders; change of condition recognition and notification to providers; prompt notification to providers, all attempts to notify medical staff and RP will be documented in residents medical record; notifications to require medical staff of weight changes as ordered. SOB, weight gain in CHF resident causing SOB; policy on physician and other communication /change in condition policy added and packet on the Management of heart failure preventing and managing exacerbations & comorbidities.
- Record review of education provided to the only 2 agency nurse staff working revealed education included change of condition and CHF education.
- Record review of an email from the DON to RN C revealed communication with RN C on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- Record review of an email from the DON to LVN B revealed communication with LVN B on change of conditions and early warning signs of CHF exacerbation and the need to notify/ Management of Heart Failure.
- Record review of text messages from the DON to LVN A revealed LVN A was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- Record review of text messages from DON to LVN D revealed LVN D was not working but was sent in-services and education was provided on change of conditions and early warning signs of CHF exacerbation and the need to notify.
- In-service training and verbal assessment for LVN E prior to her shift on changes of condition and the need to notify providers, including a PowerPoint on CHF management.
- In-service training and verbal quiz for LVN F prior to her shift on changes of condition, who to notify, weight gain, CHF management including s/s and concerns to look for.
- Ongoing training to any oncoming agency, PRN, or new staff.
- Review completed on all current CHF residents and there were no concerns with the orders and none required to be seen by a CHF clinic at the time of review.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care to a resident who required continuous oxygen therapy. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), was sent to medical appointments on two occasions with empty portable oxygen tanks. This resulted in the resident experiencing shortness of breath, anxiety, and confusion due to low oxygen levels. The resident's care plan did not adequately address her need for oxygen therapy, and there was a lack of proper monitoring and verification of oxygen supply before her appointments. Interviews with the resident, her private caregiver, and the responsible party revealed that the issue of empty oxygen tanks had been a recurring problem. Despite a grievance filed in January and an emergency care-plan meeting to address the issue, the facility staff failed to consistently check and ensure the oxygen tanks were full before the resident's medical appointments. The resident's oxygen saturation levels dropped to critically low levels during these appointments, necessitating intervention by the medical clinic staff to stabilize her condition. The facility's interim Director of Nursing (DON) and Administrator were unaware of the emergency plan for increased monitoring of the resident's oxygen needs. The facility had recently acquired new oxygen regulators, but staff were not adequately trained on their use, leading to improper attachment and monitoring of the oxygen tanks. The lack of adherence to the facility's oxygen therapy policy and the failure to ensure the resident's oxygen needs were met resulted in an Immediate Jeopardy situation, placing the resident at risk of harm.
Failure to Implement Comprehensive Care Plan for Resident with COPD and CHF
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, who was admitted with diagnoses including acute on chronic systolic heart failure and chronic obstructive pulmonary disease. The care plan did not address the resident's need for oxygen, monitoring for shortness of breath, or the requirement for specialty medical appointments related to her conditions. Additionally, the care plan did not account for the resident's need for substantial assistance with activities of daily living such as showering, dressing, and toileting hygiene. The resident's medical records indicated she required continuous oxygen therapy and had specific physician orders for oxygen use and monitoring. However, the facility did not ensure the oxygen tanks were properly filled and functioning during her medical appointments, leading to instances where the resident was transported with empty oxygen tanks. This oversight resulted in the resident experiencing confusion, anxiety, and difficulty breathing, as reported by both the resident and her responsible party. Interviews with facility staff revealed a lack of coordination and responsibility in updating the resident's care plan. The MDS Coordinator acknowledged the absence of a care plan for the resident's COPD, CHF, and oxygen use, citing logistical challenges in updating care plans during meetings. The Interim DON confirmed that the care plan should have included interventions and monitoring for the resident's conditions, but these were not implemented, potentially affecting the resident's care and well-being.
Failure to Follow Physician Orders for Resident Weights
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. Specifically, the facility did not weigh three residents according to physician orders. Resident #1, a female with diagnoses including congestive heart failure, edema, hypertension, and type II diabetes, was ordered daily weights but was only weighed on five occasions over a two-week period. Resident #2, a male with severe cognitive impairment and diagnoses including acute kidney failure and congestive heart failure, was also ordered daily weights but was only weighed once over a three-week period. Resident #3, a female with type II diabetes, congestive heart failure, morbid obesity, and pressure ulcers, was ordered daily weights but was weighed only four times over a two-month period. The Director of Nursing (DON) acknowledged that physician orders should always be followed and emphasized the importance of regular weighing for residents with congestive heart failure to monitor for excess fluid on the heart. The facility's in-service training on weights highlighted the necessity of collecting weights on the day they are due. However, the facility's Physician Orders Policy did not address the importance of following physician orders, contributing to the oversight in monitoring the residents' weights as prescribed.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in oxygen therapy management. Resident #2, a male with severe cognitive impairment and multiple health issues, was observed using an oxygen concentrator without a physician's order or an 'Oxygen in Use' sign on his door. His care plan and physician orders did not reflect any need for continuous oxygen therapy, indicating a lack of proper documentation and oversight. Resident #4, a male with chronic obstructive pulmonary disease and no cognitive impairment, was found with an empty oxygen tank while eating lunch in the dining room. His oxygen tubing was not bagged and was left on the floor, posing a risk of infection and tripping hazards. Despite having a physician's order for continuous oxygen therapy, his oxygen saturation was not adequately monitored, and staff failed to ensure his oxygen supply was maintained. Resident #6, a female with severe cognitive impairment and a history of stroke, was observed with her nasal cannula tubing disconnected from the oxygen concentrator, and the water cannister was empty. Although her oxygen saturation was checked and found to be low, staff did not immediately address the disconnection issue. The facility's Director of Nursing acknowledged the importance of proper oxygen administration and monitoring but noted that the facility's practices were not consistently followed.
Infection Control Deficiency Due to Non-Compliance with Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two separate incidents involving staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. In the first incident, a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while providing care to a resident with a wound on EBP. Despite having received training on EBP, the CNA admitted to not wearing a gown or mask because she did not notice the sign indicating the need for PPE on the resident's door. In the second incident, a Licensed Vocational Nurse (LVN) used a pulse oximeter on a resident on EBP for catheter use and failed to clean or sanitize the device before placing it back in her pocket. The LVN acknowledged the need for cleaning equipment used on multiple residents but did not have sanitizing wipes readily available near the resident's room. The LVN also admitted to using a sanitizing wipe to clean her pocket, which was not an acceptable practice according to the facility's Director of Nursing (DON). Interviews with the Assistant Director of Nursing (ADON) and the DON revealed that both were responsible for staff training on infection control and expected staff to follow EBP protocols, including wearing appropriate PPE and not placing equipment in pockets. The facility's policy on EBP required the use of gowns and gloves during high-contact resident care activities, and signage was posted to indicate the necessary precautions. However, the staff's failure to adhere to these protocols could potentially lead to the spread of infections among residents.
Failure to Include Critical Medications in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. Specifically, the care plans for two residents did not include anticoagulant medications, one resident's care plan omitted opioid medication, and another resident's care plan failed to include antiplatelet medication. This oversight could potentially place residents at risk for not receiving necessary care and services or having important care needs identified and met. Resident #10, a severely cognitively impaired female with diagnoses including cerebral infarction, dysphagia, dementia, and hypertension, was receiving anticoagulant medication Eliquis as per physician's orders. However, her care plan did not reflect this medication. Similarly, Resident #39, also severely cognitively impaired with diagnoses including cerebral infarction and anxiety, was on Eliquis, but her care plan did not include this medication. Both residents were observed to be unaware of their surroundings, and no visible bruising was noted on Resident #10. Resident #12, a cognitively intact male with a history of traumatic brain injury, dysphagia, and congestive heart failure, was receiving opioid medication acetaminophen-codeine, but this was not included in his care plan. Resident #57, a severely cognitively impaired male with diagnoses including anxiety, dementia, and atrial fibrillation, was on aspirin, an antiplatelet medication, which was not reflected in his care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the updating and accuracy of care plans, with the MDS coordinator and DON acknowledging the oversight and the potential negative effects of not monitoring medications in care plans.
Failure to Provide Scheduled Bathing for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This deficiency was observed in four residents who were dependent on staff for assistance with bathing. The facility's records indicated that these residents did not receive showers or bed baths as scheduled, and there was no documentation of refusal of care by the residents. For instance, one resident, who was cognitively intact and dependent on staff for bathing, did not receive a shower or bed bath on multiple scheduled days, and there was no indication that she refused care. Another resident, who had moderate cognitive impairment and required substantial assistance with bathing, missed seven scheduled shower opportunities over a 14-day period. Despite the resident expressing a desire for consistent showers, the facility's records did not indicate any refusals of care. Similarly, a third resident, who was cognitively intact and dependent on staff for bathing, was only bathed twice within a 17-day period, despite being scheduled for more frequent showers. This resident expressed a desire to feel clean but noted the difficulty staff had in using a mechanical lift for his showers. The fourth resident, who had severely impaired cognition and was unable to refuse care, was only bathed three times within a 17-day period. The resident's family member expressed concern about the lack of showers and noted that the resident was nonverbal and incapable of refusing care. Interviews with staff revealed inconsistencies in the documentation and reporting of shower refusals, as well as challenges in staffing that may have contributed to the missed showers. The facility's policy required necessary care to ensure residents maintained proper hygiene, but this was not consistently followed.
Failure to Conduct Weekly Skin Assessments for Residents at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards to prevent and treat pressure ulcers. Specifically, the facility did not complete weekly skin assessments for three residents, which were ordered by physicians. These residents were at risk for pressure ulcers due to their medical conditions, and the lack of assessments could lead to the development or worsening of pressure ulcers. Resident #3, a cognitively intact female with paraplegia and a stage 3 pressure ulcer, did not receive the required weekly skin inspections from December 1 to December 17, 2024. Similarly, Resident #41, a cognitively intact male with a history of pressure ulcers, also missed weekly skin inspections during the same period. Resident #52, who had severely impaired cognition and was dependent on others for bathing, only received one skin inspection during the first half of December 2024, despite being at risk for pressure ulcers. Interviews with facility staff, including LVNs and the DON, revealed that the responsibility for completing skin assessments lay with the nurses. However, the assessments were not completed due to reliance on agency nurses, making it difficult to ensure tasks were completed. The facility's policy required documentation of care and treatment, but the skin assessment policy was not provided upon request. The failure to conduct these assessments could lead to undetected skin issues and worsening outcomes for residents.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate resident assessments for three residents, leading to deficiencies in their comprehensive assessments. Resident #39's quarterly MDS assessment did not reflect her hospice services, despite physician orders and care plans indicating she was on hospice care. This oversight could result in inadequate care planning and service provision for her end-of-life needs. Resident #42's annual MDS assessment inaccurately documented her medication regimen, listing an anticoagulant instead of the antiplatelet medication she was actually receiving, as per her physician's orders and care plan. This discrepancy could lead to inappropriate monitoring and management of her medication, potentially affecting her treatment outcomes. Similarly, Resident #57's admission MDS assessment incorrectly recorded an anticoagulant medication instead of the antiplatelet medication he was prescribed. His care plan did not address the antiplatelet medication, which could result in a lack of necessary monitoring and interventions. Interviews with the MDS nurse and DON revealed that the responsibility for accurate MDS assessments lies with the MDS nurse and corporate oversight, highlighting a lapse in the facility's assessment processes.
Medication Cart Deficiencies and Improper Storage Practices
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, as observed in the medication carts for the 100, 200, and 300 halls. Thirteen unidentified loose pills were found in these carts, and a personal purse was stored in the bottom drawer of the medication cart for the 200 and half of the 300 hall. These practices could lead to drug diversion due to medications not being properly disposed of and secured. Interviews with multiple staff members, including Medication Aides (MAs) and Licensed Vocational Nurses (LVNs), revealed inconsistencies in handling loose pills and personal items in medication carts. MA E admitted to disposing of loose pills when noticed but acknowledged that routine checks of blister packs could prevent pills from falling out. MA F and LVN A both stated that personal items should not be stored in medication carts due to potential cross-contamination and theft risks. However, there was uncertainty among staff about specific policies regarding loose pills and personal items in medication carts. The Director of Nursing (DON) confirmed that it is not acceptable for staff to store personal items in medication carts and acknowledged the potential for theft and contamination. The DON was unsure if there was a specific policy on loose pills but mentioned that staff are trained during monthly audits. The facility's Medication Management Program outlines that unused doses should be destroyed following facility policy, but the report indicates a lack of consistent adherence to these procedures.
Inadequate Supervision and Improper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure adequate supervision and proper use of assistance devices for Resident #1, leading to an accident during a transfer using a mechanical lift. Resident #1, a female with multiple medical conditions including a fracture of the left femur, poly osteoarthritis, and hemiplegia, was being transferred from her wheelchair to her bed. The care plan specified the use of a mechanical lift for transfers, but the CNAs involved did not position the resident correctly in the lift sling, nor did they ensure adequate space for the lift's operation. During the transfer, CNA B did not position Resident #1 in the center of the lift sling, and CNA D failed to maintain a hand on the resident for support. The room's limited space further complicated the transfer, as the lift could not be maneuvered properly. As a result, Resident #1 leaned forward and slid out of the sling, falling to the floor and landing on the metal leg extensions of the lift. This incident was captured on video, which showed the resident tilting to the left and not being over the bed at the time of the fall. Following the fall, Resident #1 was assessed and initially found to have no injuries, but later x-rays revealed an acute fracture of the distal femur. Interviews with staff indicated that the room's arrangement and the resident's positioning in the sling were contributing factors to the incident. The facility's policy on mechanical lifts emphasized the need for a clear path and adequate space, which was not adhered to in this case.
Failure to Provide Timely Meals
Penalty
Summary
The facility failed to ensure that each resident received at least three meals daily at regular times comparable to normal mealtimes in the community. This deficiency was observed in five residents, who experienced delays in receiving their meals, leading to feelings of hunger, agitation, and diminished self-worth. For instance, Resident #1 did not receive his lunch tray on time and expressed hunger and frustration. Resident #2 often missed breakfast before leaving for dialysis and sometimes went without eating until dinner. Resident #3 reported feeling unimportant and hungry due to late meal service, while Resident #4 and Resident #5 also experienced delays in receiving their meals, with Resident #5 noting that this issue had persisted for about two years and had been discussed in resident council meetings without resolution. Observations on specific dates revealed that meal trays were not served at the posted times. For example, on one occasion, no lunch trays were served in the dining room by 1:00 PM, and on another, breakfast trays were not delivered by 8:24 AM. Interviews with staff members confirmed that meals had been consistently served late for a couple of months, causing residents to become agitated and upset. One staff member mentioned that meals were typically an hour late, and residents were unhappy with the delays. Despite these observations and resident complaints, the Administrator did not acknowledge that meals were being served late. The facility's nutrition policies and procedures, dated June 2023, specified that meals should be served at the posted times, but this was not adhered to, resulting in the deficiency. The failure to provide timely meals placed residents at risk of malnutrition, dehydration, and decreased quality of life.
Failure to Provide Special Eating Equipment and Utensils
Penalty
Summary
The facility failed to provide special eating equipment and utensils for residents who needed them, as well as appropriate assistance during meals and snacks. This deficiency was observed in four residents. Resident #1, who required finger foods due to spastic hemiplegia and other conditions, was not provided with the appropriate diet, resulting in spilled scrambled eggs on the dining table and floor. Resident #6, who had severe cognitive impairment and required built-up and right-angled utensils along with a two-handled cup, was not provided with these items during both breakfast and lunch. Resident #7, who required built-up utensils, was observed eating with her hands due to the absence of these utensils. Resident #8, who needed weighted utensils due to severe cognitive impairment and other conditions, was also not provided with the necessary equipment, leading to spilled food on the table and floor during both breakfast and lunch. Interviews with the DON and AD confirmed the importance of these adaptive devices for adequate nutrition and dignity during meals. The facility's Nutrition Policies and Procedures were not followed, as the meal trays did not include the required adaptive equipment listed on the residents' tray tickets.
Infection Control Deficiency in Blood Sugar Checks and Insulin Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to improper procedures during blood sugar checks for two residents. LVN A did not use a clean gauze to wipe the residents' fingers after collecting blood samples and reused the alcohol pad instead. Additionally, LVN A did not properly clean Resident #11's skin surface before administering insulin, using a back-and-forth motion instead of the recommended circular motion. These actions were observed during blood sugar checks and insulin administration for Resident #10 and Resident #11, both of whom were cognitively intact and had multiple medical diagnoses including Type 2 Diabetes and Hypertension. During interviews, LVN A admitted to reusing alcohol pads and not following proper cleaning procedures, despite being trained otherwise. The DON confirmed that the correct procedure involves using a clean gauze and cleaning injection sites in a circular motion. The facility's policies and procedures, as well as the Lippincott's blood glucose monitoring procedure, were reviewed and found to support the correct practices that were not followed by LVN A. This failure in infection control practices could lead to the spread of infections among residents.
Failure to Notify Responsible Party Before Resident Transfer
Penalty
Summary
The facility failed to inform the responsible party (RP) of a decision to transfer a resident to another facility. Resident #9, a female with severe cognitive impairment and multiple diagnoses including Intellectual Disability, Bipolar Disorder, and Type 2 Diabetes, was transferred without the RP's approval. The RP had initially given permission for referral packets to be sent to other nursing facilities but had requested to be contacted before any transfer was finalized. However, the facility did not follow through with this request, leading to the resident being moved without the RP's knowledge or consent. The social worker (SW) initiated the referral process and informed the RP about the resident's behaviors, but she was out sick when the referral was accepted. The Admission Coordinator (ADMC) assumed the SW had notified the RP and proceeded with the transfer arrangements. The SW and ADMC both assumed the other had communicated with the RP, resulting in a lack of proper notification. The facility's policy on resident rights emphasizes the importance of involving residents and their representatives in significant decisions, but this was not adhered to in this case.
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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