The Heights Of Bulverde
Inspection history, citations, penalties and survey trends for this long-term care facility in Spring Branch, Texas.
- Location
- 384 Harmony Hills, Spring Branch, Texas 78070
- CMS Provider Number
- 676418
- Inspections on file
- 44
- Latest survey
- January 13, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at The Heights Of Bulverde during CMS and state inspections, most recent first.
A resident with diabetes, chronic kidney disease, and an open coccyx wound was receiving daily wound care, with staff wearing gowns and gloves during treatment, but the facility failed to consistently implement its enhanced barrier precautions (EBP) process. On observation, the room initially had a PPE cart but no EBP signage posted at the doorway, even though later that day two EBP signs were present. Record review showed physician orders for wound care but no order for EBP, despite the resident’s care plan indicating EBP practices as clinically indicated. An LVN, the wound treatment nurse, and the Administrator all stated that residents on EBP should have a physician order and door signage identifying the need for EBP, in accordance with the facility’s infection prevention and control policy, which calls for EBP for residents with significant wounds requiring dressings.
Two residents did not have initial physician visit notes documented in their medical records for over 90 days after admission, and wound care was not documented on three occasions for a resident with a stage 3 pressure wound. Facility staff confirmed the missing documentation, and the physician acknowledged failing to send required records. Nursing staff interviews indicated wound care may have been provided but not recorded, with no documentation to confirm completion.
A resident with Alzheimer's disease and moderate cognitive impairment was transferred to a secure unit without a physician order, documented clinical criteria, or evidence of exit-seeking behavior. Required assessments and family consent were not present in the record, and facility staff could not provide documentation supporting the transfer. The resident's family was notified after the move and did not consent, ultimately requesting discharge.
Surveyors observed clean resident clothing spilling onto the laundry room floor due to a torn bag and mechanical lift slings with straps touching the floor, indicating improper storage practices. Interviews with the new laundry manager, DNS, and administrator confirmed recent staffing changes and ongoing issues in the laundry department, with no mention of proper sanitation procedures for clothing or equipment.
A resident with multiple chronic conditions had an indwelling urinary catheter placed for urinary retention, but the facility failed to ensure the electronic clinical record contained a physician's order for the catheter and did not discontinue the previous hospice order when the resident switched hospice providers. Documentation of catheter care was also missing, despite nursing notes and care plans referencing the catheter's use and replacement.
A resident with multiple chronic conditions and an indwelling urinary catheter placed for urinary retention was not accurately coded as having the catheter on the Quarterly MDS assessment. Despite documentation in care plans and hospice records confirming the catheter's presence and care, the MDS nurse did not mark it due to incomplete charting and oversight. Interviews and record reviews confirmed the catheter was in place and managed by both facility and hospice staff, but the required assessment was not completed accurately.
A resident with multiple chronic conditions had an indwelling urinary catheter in place for an extended period without a corresponding physician order in the electronic record, and there was no documentation of catheter care or timely catheter replacement as required. Staff interviews confirmed that catheter care and replacements were performed, but these actions were not consistently documented, and the facility's policy for assessment and documentation was not followed.
Surveyors found that kitchen staff did not consistently label and date trays of prepared beverages stored in the refrigerator, and a soup warmer with soup was left out overnight in the dining room without proper labeling or storage. Staff interviews confirmed that required food safety procedures were not followed, despite previous training and facility policy.
A resident with moderate cognitive impairment had conflicting documentation regarding code status, including a face sheet and care plan indicating full code, while a signed OOH-DNR and hospice orders were also present. The resident expressed a wish to receive CPR, but was not present at the last care plan meeting and had not signed consents for hospice or DNR. Staff interviews confirmed awareness of the discrepancies and lack of proper updates to the resident's records.
A resident with moderate cognitive impairment had conflicting documentation regarding code status, with the face sheet and care plan listing full code while a signed OOH-DNR was present in the records. The resident had not signed consents for hospice or DNR, and staff interviews confirmed the discrepancies and lack of accurate updates to the resident's wishes.
A resident with significant physical and cognitive impairments, who was care planned to use a pad-type call light due to difficulty with a traditional call light, was not consistently provided with the required device. Observations and interviews showed the resident struggled to summon assistance and often relied on a roommate or self-ambulation to get help, while staff were unaware the intervention was not in place as documented in the care plan.
A nurse was observed pouring multiple oral tablets from bulk bottles into her bare hand, selecting one to administer to a resident with severe cognitive impairment and returning the rest to the bottle, in violation of facility policy. This resulted in a medication error rate of 8%, exceeding the 5% threshold.
A box containing a [NAME] boot, a wet compression dressing, was found in a medication room without an expiration date on its packaging. The date had been torn off, and neither the DCO nor other staff could explain the missing information. Facility policy and staff interviews confirmed the necessity of expiration dates for medication storage.
A resident with moderate cognitive impairment and multiple diagnoses had a discrepancy between the code status documented in the medical record and his expressed wishes for CPR. The resident's records showed an OOH-DNR order without his consent, and he was not present at the last care plan meeting. Staff confirmed the records did not reflect the resident's current wishes, resulting in incomplete and inaccurate documentation.
An LVN was observed pouring oral medications from bulk bottles into her bare hand and returning unused tablets to the bottles during medication administration for a resident. The LVN acknowledged this was not proper procedure, and the DON confirmed that staff should not touch medications with bare hands or return them to stock bottles, as per facility policy.
Two residents did not have required weekly Skin & Wound- Total Body Skin Assessments documented in their EMRs for several weeks, despite orders and reminders in place. Staff interviews revealed confusion about documentation procedures, with some LPNs marking assessments as administered without completing the required record. The facility's policy required weekly documentation by a licensed nurse, but this was not consistently followed, resulting in incomplete clinical records.
Two residents with documented falls, including one with hemiplegia and another with Parkinsonism, were not accurately coded for these incidents in their MDS assessments, despite supporting nursing notes and post-fall reviews. The MDS assessments failed to reflect both unwitnessed and minor-injury falls, even though the facility's process required review of such events, and the responsible staff acknowledged oversight in documentation.
The facility did not consistently record or monitor food and beverage temperatures as required, with missing documentation for several meals and drinks over multiple days. Dietary staff and supervisors acknowledged missed checks and incomplete logs, and some staff were not trained to perform temperature checks. No foodborne illness incidents were reported.
A resident with a history of dementia and schizophrenia accessed and ingested wet wipes that were left accessible in the memory care unit, leading to fatal choking. Staff had not previously identified the risk of ingesting non-food items, and wet wipes were routinely available in resident bathrooms. The care plan did not address this specific hazard, and no unusual behavior was observed prior to the incident.
The facility did not report two separate incidents involving suspected abuse, neglect, or injuries of unknown origin to the State Survey Agency within the required timeframes. In one case, a male resident died after ingesting wet wipes, and in another, a female resident was found with unexplained facial bruising and a skin tear. In both situations, required notifications and investigations were not completed or documented as per facility policy.
A resident with advanced dementia and communication deficits sustained a facial bruise and forearm skin tear of unknown origin. Despite concerns raised by a visitor and documentation by nursing staff, there was no evidence that the incident was investigated or reported to management or authorities as required by facility policy. Key staff, including the DON and Administrator, were unaware of the injury, and no incident report was filed.
A resident with cognitive and mobility impairments developed a pressure wound on the left heel, but the facility did not update the care plan to address this new condition for over a month. Although physician orders for wound care and heel offloading were present, the care plan lacked specific interventions, and documentation of preventive measures was minimal. Staff relied on verbal communication rather than timely care plan revisions, contrary to facility policy.
Staff failed to follow infection control protocols by not wearing required PPE, such as gowns and gloves, during high-contact care for a resident on enhanced barrier precautions, and by transporting soiled linens through the hallway without proper containment. Inadequate staff training and unclear procedures contributed to these lapses.
The facility failed to implement comprehensive care plans for two residents, leading to deficiencies in care. One resident's plan did not reflect the use of a sit-to-stand lift for ADL care, despite their ability to bear weight on one side. Another resident's plan failed to indicate the need for substantial assistance with eating, as their ability to feed themselves had declined. These discrepancies were confirmed through staff interviews and record reviews.
Two residents in a LTC facility did not receive their prescribed medications due to communication failures and inadequate medication reordering processes. One resident missed doses of an antianxiety medication because staff were not informed of her medical appointments. Another resident, under hospice care, did not receive her fentanyl patch for pain relief on multiple occasions due to delays in medication reordering. These deficiencies highlight significant lapses in the facility's pharmaceutical services.
The facility failed to provide a safe environment and adequate supervision for residents, leading to multiple deficiencies. A resident experienced discomfort during a transfer by a single CNA, despite needing two-person assistance. Four other residents had discrepancies between their assessments and care plans regarding mechanical lift assistance. Another resident, a high fall risk, fell multiple times and sustained a head injury due to inconsistent use of fall mats.
The facility's kitchen was found to have multiple deficiencies, including improper storage of frozen foods, personal items in resident food storage areas, and significant cleanliness issues. Equipment such as the toaster, microwave, and fryer were soiled, and dietary aides failed to wear required beard nets. These practices could lead to foodborne illness, as noted in the facility's sanitation policy.
The facility failed to properly dispose of garbage and refuse, resulting in an unsanitary environment near the dumpsters. Used fryer oil had spilled from two forty-gallon drums with loose lids, and a large kitchen pot full of oil was found without a lid. The area was also littered with paper and cardboard. The Dietary Manager, new to the position, was unaware of how to request oil removal, and the Maintenance Director confirmed the potential hazards. The facility's policy on maintaining clean garbage receptacles was not followed.
The facility failed to maintain hygiene and grooming for three residents. One resident did not receive scheduled showers, leading to feelings of neglect and a foul bathroom odor. Another resident wore a dirty t-shirt due to a lack of clean clothing, and staff did not address the issue. A third resident with Alzheimer's was not groomed as scheduled, leaving facial hair and long eyebrows untrimmed. Staff interviews revealed misunderstandings and lack of communication regarding care responsibilities.
A LTC facility reported a 10% medication error rate involving two residents. An LVN failed to perform a safety check on an insulin pen, resulting in incorrect dosing, while a Medication Aide administered medications 40 minutes late. The facility's policies on medication administration were not provided.
A LTC facility failed to ensure residents were free from significant medication errors. An LVN did not perform a safety check on an insulin pen before administering insulin, and a Medication Aide administered medications late to three residents due to workload and residents' preferences. The facility's policy on timely medication administration was not provided, and the late administrations were not reported to the DON.
The facility's kitchen was found to have an ineffective pest control program, with numerous flies observed in the food preparation area, particularly near fresh bananas. Dietary Aide Y confirmed the ongoing issue of flies in the kitchen. The pest control company visited bimonthly, and the facility's policy requires an environment free of pests.
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to three residents discharged from skilled services with Medicare benefits remaining. A review revealed that only one out of twenty-three residents discharged in the past six months received a NOMNC. Interviews confirmed the facility's practice of not issuing NOMNCs to residents returning home, and the absence of a policy on this matter.
A resident with Depression and Generalized Anxiety Disorder experienced a persistent foul odor in her bathroom, reported since admission. Despite notifying staff, the sulfur-like smell continued, affecting her comfort and willingness to use the facilities. Maintenance staff acknowledged the issue, linked to dry p-traps, and attempted temporary fixes, but the problem remained unresolved.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall resulting in a major head injury. The facility failed to report the incident to state authorities within the required timeframe and did not investigate it per policy. The Administrator initially misunderstood the reporting requirements, believing a family member witnessed the fall, but later confirmed there was no witness. The facility's policy mandates immediate reporting of such incidents to prevent abuse and neglect.
A resident with severe cognitive impairment experienced an unwitnessed fall resulting in a major head injury. The facility failed to report the incident to HHSC within the required two-hour timeframe, as mandated by regulation. The ADM initially believed a family member witnessed the fall, but later acknowledged the event as reportable. Despite this, the incident was neither reported nor investigated, contrary to facility policy.
The facility failed to obtain physician orders for the immediate care of two residents upon admission. One resident had cradle cap, but no treatment order was obtained, while another used side rails without a physician's order. The DON acknowledged the importance of having orders for treatments and equipment.
A resident with heart failure and acute kidney failure was readmitted with encephalopathy and hyponatremia, but the facility failed to conduct a significant change MDS assessment within 14 days. The resident's condition met the criteria for a significant change, as acknowledged by the facility's staff, but the assessment was not completed, potentially impacting the care provided.
A resident at risk for pressure ulcers did not receive appropriate care as recommended by a wound specialist. Despite being dependent on staff for all ADLs and having a care plan that included heel off-loading, observations showed the resident's feet were not off-loaded, and the recommended pressure-relieving boot was not used. Interviews with staff confirmed the lack of adherence to the care plan, contributing to the development of a pressure sore.
A facility failed to provide proper catheter care for a resident, risking urinary tract infections. During care, a CNA lifted the urine collection bag above the bladder, contrary to guidelines. The resident had a history of urinary issues and required catheter care, but the facility lacked specific policies for maintaining the bag below bladder level. Interviews revealed staff were unaware of the proper procedure, and administration acknowledged the risk of infection from improper handling.
The facility failed to secure medications properly, as a nurse left a medication cart unlocked and unattended, and a resident had unsecured medicated eye drops and nasal spray at her bedside. The resident expressed concerns about timely administration, and staff were unaware of her ability to self-administer. Facility policy requires secure storage and assessment for self-administration.
The facility failed to notify physicians of abnormal lab results for two residents, one with heart and kidney issues and another with hyperkalemia and vitamin D deficiency. Despite policies requiring prompt communication of such results, there was no evidence of notification over a six-month period. Interviews revealed that standard procedures for reporting lab results were not followed.
A resident with severe protein-calorie malnutrition and other health issues was served a cheese omelet despite having a documented dislike for cheese and dairy. This oversight occurred despite the resident's care plan emphasizing the importance of adhering to dietary preferences to prevent nutritional deficits.
A facility failed to implement a policy for the safe storage of foods brought by family members, leading to a deficiency. An opened, unrefrigerated, unlabeled, and undated bottle of prune juice was found on a resident's bedside table, despite the manufacturer's label advising refrigeration after opening. The resident confirmed that her niece brings the juice and that it is stored on the bedside table due to the lack of a refrigerator. The facility's dietary services policy, revised in January 2023, requires proper storage of such foods to ensure safety and sanitation.
Failure to Implement Enhanced Barrier Precautions for Resident With Open Wound
Penalty
Summary
The deficiency involves the facility’s failure to maintain its infection prevention and control program for a resident on enhanced barrier precautions (EBP). The resident was an adult female with type 2 diabetes and chronic kidney disease who was dependent on staff for ADLs, bed mobility, and transfers. Her physician orders included treatment for an open coccyx wound with cleansing, application of calcium alginate, and a dry dressing daily and as needed, but there was no physician order for EBP related to this wound, despite facility practice and staff statements that residents on EBP should have such an order. Surveyors observed that on the morning of the survey, the resident’s room had a PPE supply cart outside the door but no EBP sign posted at the door or doorway entrance, even though the resident had an open coccyx wound and was being treated under EBP practices. Later that same day, two EBP signs were observed posted on the wall outside the resident’s room, indicating that staff and providers must wear gown and gloves for specified high-contact resident care activities, including wound care and other listed tasks. The resident confirmed she had a wound on her buttocks that nurses treated daily with cream and a dressing, and that staff wore gowns and gloves when performing wound care. Multiple staff interviews confirmed that the resident was on EBP and that facility practice required residents on EBP to be identified by a sign outside the room and to have a physician order for EBP. An LVN stated that residents with wounds were on EBP, that everyone was responsible for ensuring EBP signs were posted, and that the resident should have had a sign on her door. The wound treatment nurse stated that residents on EBP, including this resident with a coccyx wound, were identified by door signage and should have a physician order for EBP. The Administrator also stated that residents on EBP had a sign outside their room and a physician order, and that EBP should be reflected in the care plan and Kardex. The facility’s infection prevention and control policy indicated that EBP may be implemented for residents with wounds or indwelling devices and that residents with significant wounds requiring dressings should be under EBP, with gown and glove use during high-contact care activities.
Failure to Maintain Complete Medical Records and Document Wound Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by accepted professional standards. For both residents, there was no documentation of an initial physician visit note in their medical records, even after more than 90 days following admission. Review of the electronic medical record (EMR) and progress notes for both individuals did not reveal any physician or MD notes, except for a single nurse practitioner (NP) note for one resident. Interviews with facility staff, including the Director of Nursing Services (DNS) and the administrator, confirmed that physician documentation was missing and that it was the responsibility of the medical records department to ensure such documentation was present. The physician later admitted to forgetting to send the required history and physical documentation for both residents to the facility. Additionally, the facility failed to document wound care provided to one of the residents on three separate occasions, as required by the resident's treatment orders. The Treatment Administration Record (TAR) for the month in question showed blank entries for the scheduled wound care on three specific dates. Interviews with nursing staff indicated that the absence of documentation could mean the treatment was completed but not recorded, or that the nurse responsible was not present and coverage was provided by other staff. However, there was no documentation to confirm that the wound care was actually performed on those dates, nor any explanation for the missed entries. Both residents involved had significant medical histories, including diagnoses such as Alzheimer's disease, chronic kidney disease, dementia, and chronic obstructive pulmonary disease. One resident was on hospice care and had a documented stage 3 pressure wound requiring daily treatment. The lack of physician documentation and incomplete wound care records were confirmed through record review, staff interviews, and review of facility policies, which required accurate and timely documentation of care and physician services.
Failure to Obtain Physician Order and Assessment for Secure Unit Placement
Penalty
Summary
The facility failed to ensure that a resident was free from involuntary seclusion and physical restraint not required to treat medical symptoms. A male resident with diagnoses including Alzheimer's disease, muscle wasting, chronic kidney disease, and hypertension was admitted and subsequently moved to a secure/locked unit. Documentation revealed that prior to the transfer, there was no physician order, no documented clinical criteria for secure unit placement, and no evidence of exit-seeking or wandering behaviors in the resident's assessments or care plan. The resident's Minimum Data Set (MDS) at admission indicated moderate cognitive impairment but no behavioral symptoms such as wandering, and no elopement risk evaluation was found in the electronic medical record. Interviews with facility staff, including the Director of Nursing Services (DNS) and the Administrator, indicated that secure unit placement should be based on exit-seeking behavior and require both an assessment and a physician order, as well as family consent. However, the DNS could not locate the required assessment or documentation supporting the transfer, and the Administrator was unsure if the behaviors leading to the transfer were documented. The facility's policy required interdisciplinary team review and a physician order for secure unit admission, but these steps were not followed in this case. The resident's family member reported being notified of the move after it occurred and stated that she did not consent to the transfer. She also indicated that the facility did not attempt alternative interventions before moving the resident and that some of the resident's personal property was removed due to safety concerns in the secure unit. The family ultimately requested the resident's discharge from the facility. There was no documentation of a decline or negative impact on the resident as a result of the transfer, but the required assessments, orders, and consents were missing from the record.
Improper Storage of Clean Laundry and Equipment in Laundry Room
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program in the laundry room, as evidenced by improper storage of clean resident clothing and mechanical lift slings. During an observation, a bag of clean resident clothing was found with a hole in the bottom, causing clothing to spill out and come into contact with the laundry room floor. Additionally, approximately five mechanical lift slings were observed hanging off the side of a trash can, with their straps touching the floor. These practices were noted on the clean side of the laundry room, where clean items are expected to be stored in a sanitary manner. Interviews with the laundry manager, Director of Nursing Services (DNS), and the administrator revealed that the facility had recently experienced significant staffing changes in the laundry department, including the loss of the prior laundry manager and the termination of several staff members. The new laundry manager had only been in the position for two weeks and was still working to address ongoing issues. None of the interviewed staff mentioned proper procedures for the sanitary storage of clothing or equipment. Policy review showed general guidance on resident care and equipment cleaning but did not specifically address the observed deficiencies in laundry storage.
Failure to Maintain Accurate Medical Records for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had an indwelling urinary catheter. The resident, who had multiple diagnoses including high blood pressure, diabetes, Parkinson's disease, hypothyroidism, and systemic lupus erythematosus, was admitted to hospice care and had a Foley catheter placed for urinary retention. Although there was a handwritten order from the initial hospice physician for the catheter, this order was not entered into the electronic clinical record, and no new order was documented when the resident transitioned to a second hospice provider. Additionally, the order to discontinue the first hospice provider was not documented. Review of the resident's care plans and clinical records revealed inconsistencies and omissions. The quarterly MDS assessment did not indicate the presence of an indwelling urinary catheter, despite care plans and nursing notes referencing its use. The electronic physician order summary lacked any order for the catheter, and there was no documentation of catheter care being provided after the resident switched hospice providers. Nursing notes confirmed the presence and replacement of the catheter, but these actions were not consistently documented in the resident's official medical record. Interviews with nursing staff and the DON confirmed that there was no order for the indwelling urinary catheter in the electronic record and that documentation of catheter care was missing. The DON and Administrator acknowledged that the absence of proper orders and documentation could result in missed care. The facility's policy requires maintenance of complete medical records in accordance with professional standards, but this was not followed in the resident's case.
Failure to Accurately Reflect Indwelling Urinary Catheter on MDS Assessment
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident's status by not indicating the presence of an indwelling urinary catheter on the resident's Quarterly MDS. The resident, a female with multiple diagnoses including high blood pressure, diabetes, Parkinson's disease, hypothyroidism, and systemic lupus erythematosus, was admitted to hospice care and had an indwelling urinary catheter placed due to urinary retention. Documentation in the clinical record, care plans, and hospice plans of care confirmed the presence and ongoing management of the catheter, including notes of catheter care and replacement. Despite this, the Quarterly MDS assessment did not mark that the resident had an indwelling urinary catheter. The MDS nurse stated that the omission was due to reliance on the clinical record and Point of Care charting, which did not reflect the catheter, and acknowledged that the nurse's note indicating catheter replacement was overlooked. The Director of Nursing also confirmed that there was no physician order for the catheter in the clinical record and no documentation of catheter care, and agreed that the MDS should have indicated the presence of the catheter. Interviews with nursing staff and review of the resident's records revealed that the indwelling urinary catheter had been in place since the resident's admission to hospice care, and both facility and hospice staff were responsible for its care. The facility's policy and the CMS RAI Manual require accurate assessment and documentation of such devices, including direct observation and review of all relevant records. The failure to accurately code the presence of the indwelling urinary catheter on the MDS was attributed to incomplete documentation and oversight during the assessment process.
Failure to Document and Maintain Physician Orders for Indwelling Urinary Catheter
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including Parkinson's disease, diabetes, and systemic lupus erythematosus, did not receive appropriate treatment and services related to the management of an indwelling urinary catheter. The facility failed to ensure that a physician's order for the indwelling urinary catheter, which had been in place for 95 days, was entered into the electronic physician orders. Additionally, there was no documentation of when catheter care was provided or if the catheter had been replaced every 30 days as ordered by hospice services. Record reviews revealed that although the resident's care plan addressed the risk of infection related to the indwelling catheter, the electronic clinical record lacked an active order for the catheter. The medication administration records (MAR/TAR) for several months showed no documentation of catheter care or catheter replacement. Nursing notes indicated that the catheter was replaced on at least two occasions by hospice nurses, but these actions were not consistently documented in the resident's clinical record. Interviews with nursing staff confirmed that catheter care was performed and that the hospice nurse was responsible for changing the catheter, but staff were unclear about documentation requirements and acknowledged the absence of a physician's order in the electronic record. The facility's policy required assessment, documentation, and monitoring of catheter use and care, but these procedures were not followed. The Director of Nursing and the Administrator both acknowledged that the lack of a physician's order and failure to document catheter care could result in missed care and inadequate monitoring. Observations confirmed the presence of the indwelling catheter, and interviews with staff and the resident's private sitter corroborated that catheter care was being provided, albeit without proper documentation.
Failure to Label, Date, and Properly Store Food and Beverages
Penalty
Summary
Surveyors observed that the facility failed to properly label and date trays of prepared beverages stored in the kitchen refrigerator. Multiple trays containing milk, juice, tea, and water were found without any dates or labels, and one tray had two conflicting dates. Staff interviews confirmed that the trays were prepared by various kitchen staff and placed in the refrigerator without following the required labeling and dating procedures, despite previous in-service training on this topic. The staff acknowledged that labeling and dating are necessary to track when items are placed in storage and to prevent serving expired or unsafe food. Additionally, a soup warmer containing soup was found left out overnight in the main dining room, unplugged and not warm, with the lid partially open and no date or label present. Staff interviews revealed that the soup had been put out at lunch the previous day and was not returned to the kitchen as required. Both the kitchen staff and administration confirmed that the soup should have been removed after lunch and that failure to do so could result in food safety concerns. Facility policy and previous training required all refrigerated and prepared foods to be labeled and dated, but these procedures were not consistently followed.
Failure to Ensure Accurate Communication and Implementation of Code Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was fully informed of, and able to participate in, decisions regarding their code status and advance directives. Record review revealed a discrepancy in the resident's medical chart, with conflicting information between the face sheet, care plan, OOH-DNR document, and physician orders. The face sheet and care plan indicated full code status, while a signed OOH-DNR was present in the electronic health record, and hospice orders were also noted. No DNR order was found in the physician orders section, and contradictory information was present regarding code status and hospice care. Interviews with the resident, social worker, DON, and administrator confirmed the existence of these discrepancies. The resident expressed a desire to receive CPR, while the chart contained a DNR order signed by physicians, without the resident's consent or presence at the last care plan meeting. The social worker and DON acknowledged the inconsistencies, and the administrator stated that records should be updated at care plan meetings, with the social worker responsible for ensuring accuracy. Facility policy requires residents to be informed and able to exercise their rights, but this was not followed in this case.
Failure to Accurately Document and Implement Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directive wishes were accurately documented and implemented. There was a discrepancy in the resident's records: the face sheet and care plan listed the resident as full code, while a signed Out-of-Hospital Do Not Resuscitate (OOH-DNR) order was found in the miscellaneous documents section. Additionally, there were no DNR orders in the electronic health record, and the resident's orders reflected hospice care with contradictory information regarding code status. The resident had not signed any consents for hospice or the OOH-DNR, and the last care plan meeting did not include the resident. Interviews with facility staff, including the social worker, DON, and administrator, confirmed awareness of the discrepancies and acknowledged that the resident's wishes were not accurately reflected or updated in the records. The facility's policy requires that the medical record and plan of care reflect the resident's wishes and physician orders, but this was not followed in this case. The resident, who had moderate cognitive impairment and required supervision for daily activities, expressed during an interview that he would want CPR if needed, further highlighting the inconsistency between his stated wishes and the documented directives.
Failure to Implement Care Plan Intervention for Specialized Call Light
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including muscle wasting, multiple sclerosis, and chronic pain syndrome. The resident was assessed as having moderate cognitive impairment and required substantial to maximal assistance with mobility and transfers. The care plan, initiated in March, specified the use of a pad-type call light as an intervention due to the resident's inability to use a traditional call light. Despite this documented intervention, observations and interviews revealed that the resident did not consistently have access to the pad-type call light. On multiple occasions, the resident struggled to use the traditional call light and often relied on a roommate or self-ambulation to seek staff assistance. Staff interviews indicated a lack of awareness regarding the resident's need for the specialized call light, and the care plan intervention was not consistently communicated or implemented. The facility's own policies require that care plans include measurable objectives and appropriate interventions to meet residents' needs, and that staff follow and update care plans as necessary. However, the failure to provide the pad-type call light as care planned resulted in the resident not receiving the necessary assistance to alert staff, as documented through direct observation, resident statements, and staff interviews.
Medication Error Rate Exceeds 5% Due to Improper Handling
Penalty
Summary
A deficiency occurred when a nurse (LVN) failed to follow proper medication administration procedures for a resident with severe cognitive impairment and multiple health conditions, including malnutrition and immunodeficiency. During a medication pass, the LVN poured several oral tablets from bulk stock bottles into her bare hand, selected one tablet to administer, and returned the remaining tablets to the bottle. This process was observed with both cyanocobalamin (Vitamin B12) and ferrous sulfate (iron) tablets. The LVN acknowledged during the observation that this was not the correct procedure and that she should not have touched the medications with her bare hand or returned them to the bottle. The facility's medication administration policy, revised in January 2024, specifically instructed staff not to touch oral medications with bare hands. The Director of Nursing confirmed that the LVN's actions were not in line with facility policy and explained the correct method for separating tablets. The survey found that the medication error rate for the observed medication pass was 8%, exceeding the acceptable threshold of 5%. The incident was documented as a failure to ensure medication error rates remained below 5% for residents reviewed for pharmacy services.
Medication Storage Lacked Expiration Date Labeling
Penalty
Summary
Surveyors observed that the facility failed to store medication with the expiration date visible on its packaging in accordance with state laws and regulations. During an inspection of the medication storage room for the 300/400 halls, a box containing a [NAME] boot, which is a wet compression dressing used for venous ulcers, was found without an expiration date. The date had been torn off the box, and there was no date on the foil package itself. The Director of Clinical Operations (DCO) was present during the observation, discarded the box, and stated she did not know why the expiration date was missing or why the item was stored in the medication room. Further interviews with the Administrator and the Director of Nursing (DON) confirmed the importance of having expiration dates on medications, as expired medications could lose potency and effectiveness. A review of the facility's Pharmacy Services policy also indicated that expiration dates are a critical element of drug labeling. The deficiency was limited to one of two medication rooms observed during the survey.
Failure to Accurately Document Resident Code Status and Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with professional standards for one resident. A review of the resident's records revealed a discrepancy between the code status documented in the electronic medical record, which indicated an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order signed by a physician, and the resident's expressed wishes during an interview, where he stated he would want CPR. The resident had not signed any consents for Hospice or OOH-DNR, and the last care plan meeting did not include the resident's participation. The social worker and Director of Nursing confirmed the discrepancy and lack of updated documentation reflecting the resident's current wishes. The resident in question had a history of cognitive impairment, dementia, depression, and anxiety, with a BIMS score indicating moderate cognitive impairment and requiring supervision for daily activities. Despite this, the facility did not ensure that the resident's expressed wishes regarding code status were accurately documented or updated in the medical record. The facility's policy states that residents have the right to be fully informed about their care and treatment, but this was not followed in this case, resulting in incomplete and inaccurate records.
Failure to Follow Infection Control Practices During Medication Administration
Penalty
Summary
A deficiency was identified when an LVN was observed administering medications to a resident without following proper infection control procedures. During medication administration, the LVN poured several oral tablets from bulk stock bottles into her bare hand, selected the required dose, and returned the unused tablets back into the original bottles. This occurred with both cyanocobalamin (Vitamin B12) and iron tablets. The LVN acknowledged during the observation that this was not the correct procedure and that she should not have touched the medications with her bare hands or returned them to the bottle after contact. The Director of Nursing (DON) confirmed that the LVN should have used the inside of the bottle lid to separate the tablets and not her hand, as touching and returning medications could introduce bacteria. Review of the facility's medication administration policy indicated that staff are instructed not to touch oral medications with their hands. The LVN's competency checklist showed she had previously met the required standards for medication administration and infection control practices.
Failure to Document Weekly Skin Assessments in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for two residents were maintained in accordance with accepted professional standards and practices. Specifically, required weekly Skin & Wound- Total Body Skin Assessments were not documented in the electronic medical record (EMR) for multiple weeks, despite being marked as administered in the Licensed Nurse Administration Records. For one resident, five weekly assessments were missing from the medical record, and for another resident, three weekly assessments were not recorded. There was no alternative documentation found in the residents' progress notes for the missing assessments. Both residents had significant medical histories, including conditions such as hemiplegia, cerebral aneurysm, multi-system degeneration, and Parkinsonism, and required varying levels of assistance with mobility. Orders were in place for weekly skin assessments to monitor for pressure injuries and other skin concerns. Interviews with staff revealed that while the assessments were scheduled and reminders were present in the EMR, the actual documentation of the assessments was inconsistent. Some staff believed that checking off the order in the administration record was sufficient, while others indicated that assessments might have been completed but not properly documented. The facility's policy required licensed nurses to conduct and document weekly skin assessments in the resident's medical record. However, the process for ensuring completion and documentation was not consistently followed. Staff interviews indicated a lack of clarity regarding where and how to document the assessments, and there was reliance on other forms of skin monitoring, such as daily care by CNAs and nurses, but without the required weekly documentation in the medical record. This resulted in incomplete clinical records for the affected residents.
Failure to Accurately Reflect Resident Falls in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the fall history of two residents. For one resident with a history of hemiplegia and a non-ruptured cerebral aneurysm, the Annual MDS assessment did not document a fall without injury that occurred earlier in the year, despite nursing progress notes and post-fall reviews clearly indicating the incident. The resident was cognitively intact and required moderate assistance with transfers, and the fall was unwitnessed but resulted in no injury. Another resident, diagnosed with multi-system degeneration of the autonomic nervous system and Parkinsonism, experienced two falls without injury and one fall with a minor injury within the look-back period for her Quarterly MDS assessment. These incidents were documented in nursing progress notes, neuro checks, and post-fall reviews, including details of abrasions and pain complaints. However, the MDS assessment for this resident did not reflect any of these falls, despite the availability of supporting documentation in the medical record. Interviews with the Nurse Assessment Coordinator and the Director of Nursing revealed that the process for completing MDS assessments involved reviewing fall-related documentation, such as UDAs and neuro checks. The Nurse Assessment Coordinator acknowledged missing the falls in the MDS due to oversight and timing issues. The facility's policy required accurate and certified assessments by qualified professionals, with the MDS serving as the clinical basis for care planning and delivery. Despite the care plans being updated, the MDS assessments did not accurately capture the residents' fall histories as required.
Failure to Accurately Document Food Temperatures in Dietary Services
Penalty
Summary
The facility failed to maintain complete and accurate food temperature records in accordance with accepted professional standards. Specifically, temperatures were not taken or logged for breakfast and lunch meals on one day, for all meals on another day, and for breakfast milk or juices over a week-long period. Observations confirmed that temperature checks were performed before one lunch meal service, but interviews with dietary staff revealed that temperature checks were missed on multiple occasions. Staff acknowledged that the dietary supervisor was aware of blanks in the temperature log, and that some staff were not trained to check temperatures or forgot to do so due to workload. Record reviews corroborated the missing temperature documentation, showing blanks in the temperature log for specific dates and meal types. The FDA Food Code was referenced, indicating the required temperature controls for food safety. Interviews with the DON and ADM confirmed their expectation that missed temperature checks should be reported and acknowledged the importance of these checks for resident safety. There were no reported incidents of foodborne illness related to these deficiencies at the time of the survey.
Failure to Prevent Resident Access to Accident Hazards Resulting in Fatal Choking Incident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was as free from accident hazards as possible, resulting in a resident accessing and ingesting wet wipes, which led to choking and death. The resident, a male with diagnoses including moderate dementia, schizophrenia, depression, neuromuscular bladder dysfunction, and benign prostatic hyperplasia, was admitted to the memory care unit due to behavioral concerns such as wandering. Despite a BIMS score indicating cognitive intactness and no evidence of depression, the resident had a history of psychiatric conditions and was being treated with antipsychotic and antidepressant medications. On the day of the incident, the resident was last seen alert and oriented, sitting on the side of his bed. Staff later found him unresponsive in his bed, and emergency measures were initiated, including CPR and a call to EMS. During intubation attempts, EMS discovered a stack of approximately 15 wet wipes lodged in the resident's esophagus, which were removed but could not be seen prior to EMS intervention. Interviews with staff revealed that wet wipes and gloves had previously been accessible in resident bathrooms, and staff had not observed any unusual behavior or signs of self-harm in the resident prior to the event. Further investigation revealed that the facility had not previously restricted access to wet wipes and similar items in the memory care unit, and staff were not aware of any specific risk of the resident ingesting non-food items. The resident's care plan included interventions for his psychiatric diagnoses but did not address the risk of ingesting hazardous items. Staff interviews confirmed that the availability of wet wipes in resident rooms was standard practice until the incident occurred, and there was no documentation of prior behaviors indicating a risk for such an event.
Removal Plan
- Director of Nursing Services/Assistant Director of Nursing Services/Charge Nurse immediately assessed the identified resident and initiated emergency response care.
- Primary care provider and responsible party notified of the incident.
- Director of Clinical Operations/Director of Nursing Services/Assistant Director of Nursing Services/IDT conducted an assessment of current residents to validate their safety and well-being.
- IDT Director of Nursing Services/Assistant Director of Nursing Services/Charge Nurse/Designee immediately inspected all resident rooms to identify and remove any items such as patient care items for added safety.
- All briefs/wipes identified in bathrooms (cabinets) were immediately removed and disposed of.
- Director of Nursing Services/Assistant Director of Nursing Services conducted rounds and staff interviews to identify any residents with poor cognition and who are at risk for ingesting nonfood items.
- IDT/Director of Nursing Services/Assistant Director of Nursing Services commenced with an audit of all residents with cognitive impairment to review and update the plan of care as indicated.
- IDT conducted an audit of all residents with a diagnosis of schizophrenia or recent change of condition concerning new onset of behaviors, worsening behaviors, or signs/symptoms of being withdrawn to ensure appropriate plan of care.
- IDT conducted a depression screen for all residents identified with behavioral concerns or changes in condition, and all positive screens were referred to the mental health provider for evaluation and treatment.
- DCO re-educated Admin/DNS/ADNS regarding Abuse & Neglect Preventing, Identifying, and Reporting all suspicions or allegations; Preventing Accidents/Incidents & Fall Prevention; Plan of Care/Kardex review; and ensuring safety concerns and appropriate interventions are noted on the plan of care and Kardex.
- All staff on leave/agency staff/PRN staff are in-serviced prior to working their shift.
- No licensed nurse, certified medication aide, or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex.
- Administrative nursing staff to provide in-service/education prior to team members working their assigned shift; these trainings will also be conducted with new hires.
- Administrator/Director of Nursing/Assistant Director of Nursing re-educated staff regarding Abuse & Neglect, Preventing Accidents/Incidents & Fall Prevention, Plan of Care/Kardex review, and ensuring safety concerns and appropriate interventions are noted on the plan of care and Kardex.
- IDT will conduct interviews with family, review of health records, and evaluate any newly admitted resident for consideration on the memory care unit to identify any behavioral concerns that would pose risk of harm to self by ingesting non-food items.
- Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will make random audits/rounds to validate the safety and well-being of residents and resident rooms at random times on random halls to identify any safety concerns.
- Director of Nurses/Assistant Director of Nurses will review all admission/re-admission care plans and Kardex to ensure any safety risks are accurately noted, and will review progress notes and risk management reports to identify any safety risks/concerns.
- Findings of audits and observations will be reported to the QAPI committee during monthly meetings to establish compliance or identify additional trainings and oversight as required.
- Administrator/Director of Nursing/Assistant Director of Nursing/Social Worker will complete all audits and they will be placed in a binder and kept for review by HHSC for the revisit to validate for compliance.
- Administrator/Director of Nursing and Medical Director conducted an Ad Hoc QAPI meeting to review the situation and the immediate corrective action plan implemented.
Failure to Timely Report Alleged Abuse, Neglect, and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse, neglect, or injuries of unknown origin to the State Survey Agency as required by regulation and facility policy. In the first instance, a male resident with diagnoses including dementia, schizophrenia, and depression died after ingesting and choking on wet wipes. Despite the unusual circumstances of the death, which involved the ingestion of a foreign object, the facility did not report the incident to the State Survey Agency. Interviews with the Administrator (ADM) and Director of Nursing (DON) revealed that they did not consider the event out of the ordinary and did not suspect foul play, even though the Medical Examiner was conducting an autopsy and the resident had no prior history of such behavior. The facility had not previously removed wipes from the environment, and only did so after the incident. In the second instance, a female resident with dementia and cognitive communication deficits was found to have a bruise on her face and a skin tear on her forearm, both of unknown origin. An anonymous source reported these injuries to nursing staff and expressed concern about possible neglect. Progress notes documented the injuries but did not indicate that the Abuse Coordinator or management were notified, nor was there evidence of an investigation or follow-up with the reporting party. The DON and ADM both denied prior knowledge of the facial injury and stated that their expectation was for immediate notification of any injuries suggestive of abuse or neglect. The facility's incident and grievance reports did not contain any entries related to these injuries. Facility policy required that all allegations or suspicions of abuse, neglect, or exploitation, including injuries of unknown source, be reported immediately, but not later than two hours if abuse or serious bodily injury was involved, or within 24 hours otherwise. In both cases, the facility failed to follow its own policy and regulatory requirements by not reporting the incidents to the State Survey Agency within the required timeframes. This failure was confirmed through interviews, record reviews, and the absence of documentation of required notifications and investigations.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate and report an injury of unknown origin sustained by a resident with significant cognitive and communication deficits, including dementia and Alzheimer's disease. On the date in question, an anonymous source observed a bruise on the resident's left lower face and a skin tear on the forearm, neither of which were present the previous day. The source notified nursing staff and expressed concern about possible neglect, but did not receive any follow-up or information about an investigation from the facility. Progress notes from two nurses documented the injuries but did not indicate that the Abuse Coordinator or facility management were notified. One nurse recalled notifying family and possibly the DON via text, but was unsure if an investigation was initiated. The DON and Administrator both denied knowledge of the facial injury and stated that they were not notified, although the DON recalled a skin tear incident. Facility incident and grievance reports contained no entries related to the injuries on the date in question. Facility policy requires that all allegations of abuse, neglect, or exploitation be investigated and reported to the appropriate authorities within five working days. In this case, there was no evidence that the injury was investigated or reported as required, and key staff members were unaware of the incident. The lack of documentation and communication regarding the injury led to a failure to comply with regulatory requirements for investigating and reporting alleged violations.
Failure to Timely Update Care Plan for Pressure Wound
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who developed a pressure wound on the left heel. Despite an initial assessment and provider notification of the skin issue, including a documented deep tissue injury and physician orders for skin prep and heel offloading, the care plan was not updated to specifically address the new wound for 40 days. The care plan only included a general focus on skin conditions and was updated with specific interventions for the wound and use of heel protectors much later. Documentation showed minimal evidence of heel offloading or use of heel protectors during this period, with only one progress note referencing the heel being floated. Interviews and record reviews revealed that the resident had significant cognitive and mobility impairments, including dementia, Alzheimer's disease, and unsteadiness on her feet. Staff interviews indicated that changes in skin condition were not promptly reflected in the care plan, and communication about interventions was reportedly handled verbally during shift reports rather than through timely care plan updates. Facility policy allowed for care plan updates as indicated, but this was not followed in the case of the resident's newly developed pressure wound.
Failure to Adhere to Infection Control Protocols and Proper Linen Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to established protocols for personal protective equipment (PPE) and linen handling. During an observation, a certified nursing assistant (CNA) provided incontinent care to a newly admitted male resident with a diagnosis of senile degeneration of the brain and an order for enhanced barrier precautions (EBP) due to a coccyx wound. The CNA attempted to exit the resident's room without removing soiled gloves and without wearing the required disposable gown, despite signage and a PPE cart being present. The CNA was redirected by a licensed vocational nurse (LVN) to remove gloves and use hand sanitizer before leaving the room, but it was confirmed that the gown was not worn during the care procedure. Further observations revealed that another CNA exited a resident's room while holding soiled linens with gloved hands and transported them through the hallway without bagging or containing them at the point of collection. This CNA reported being new to the facility, having received no training on proper linen handling or glove removal procedures, and was unclear about the requirements for PPE use in isolation rooms. The LVN confirmed that the first CNA did not wear the appropriate gown during care, and the Director of Nursing (DON) acknowledged that staff are expected to follow posted precautions and bag soiled linen before exiting rooms. A review of the facility's infection prevention and control policy indicated that EBP requires the use of gown and gloves during high-contact resident care activities, such as hygiene and wound care. The policy also referenced proper handling of laundry and linens for residents on isolation precautions but did not explicitly describe the required methods or procedures. The lack of adherence to these protocols and insufficient staff training contributed to the observed deficiencies in infection control practices.
Deficiencies in Care Plan Implementation for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For the first resident, the care plan did not accurately reflect the use of a sit-to-stand lift for activities of daily living (ADL) care, such as showering, despite the resident having the ability to bear weight on one side while seated in a wheelchair. Interviews with staff, including a CNA, the Director of Nursing (DON), and a physical therapist, confirmed that the sit-to-stand lift was used for ADL care, but this was not documented in the care plan. The care plan only mentioned the use of a Hoyer lift for transfers, which could lead to inconsistent care. The second resident's care plan failed to reflect the need for substantial assistance with eating, as indicated in the comprehensive Minimum Data Set (MDS) assessment. The resident had multiple diagnoses, including Multiple Sclerosis and Parkinson's Disease, which affected their ability to feed themselves. Interviews with a Licensed Vocational Nurse (LVN) and a Hospice Registered Nurse (RN) revealed that the resident's ability to feed themselves had declined, and there were instances where the resident was left soiled after meals. The MDS nurse acknowledged that the care plan did not accurately reflect the resident's needs and that the MDS assessment was incorrectly coded. The discrepancies between the care plans and the actual needs of the residents were confirmed through interviews with the MDS nurse and the DON. The care plans were not updated in real-time to reflect the residents' current care status, which could lead to improper care. The facility's policy on care plans emphasized the importance of including expressed preferences and maintaining the residents' highest practicable well-being, but this was not adhered to in these cases.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to missed medication doses. Resident #2 did not receive her morning dose of Buspirone HCL for anxiety on two occasions due to a lack of communication between the nursing staff. The resident was out of the facility for medical appointments, and the Certified Medication Aide (CMA) was not informed of these appointments, resulting in the missed doses. Interviews with the CMA and Licensed Vocational Nurse (LVN) confirmed that the communication breakdown was the cause of the missed medication. Resident #3 experienced multiple instances where her fentanyl patch for pain relief was not administered as ordered. The resident, who was admitted to hospice care, had a history of multiple sclerosis, Parkinson's disease, and fibromyalgia, conditions that necessitated consistent pain management. The facility's Medication Administration Record (MAR) showed several dates where the fentanyl patch was either not available or not applied, and progress notes indicated that the resident experienced pain due to these lapses. Interviews with nursing staff and the Director of Nursing (DON) revealed that medication reordering processes were not timely, contributing to the unavailability of the fentanyl patches. The facility's policy on medication administration was not adhered to, as evidenced by the repeated failures to administer medications as ordered by the physician. The lack of timely communication and reordering of medications led to significant lapses in the pharmaceutical care provided to the residents, potentially compromising their health and well-being.
Deficiencies in Resident Safety and Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for several residents, leading to multiple deficiencies. One resident experienced discomfort and pain during a transfer from bed to wheelchair by a single CNA, despite being assessed as needing assistance from two staff members for mechanical lifts. The CNA attempted to manage the transfer alone, causing the resident's toes to rub against the lift, resulting in discomfort and anxiety about falling. Four other residents were assessed as needing mechanical lifts with the aid of one person, but their care plans indicated a requirement for two-person assistance. This discrepancy between assessments and care plans suggests a lack of proper evaluation and adherence to safety protocols, potentially placing these residents at risk during transfers. Another resident, who was a high fall risk, fell multiple times and sustained a head laceration requiring sutures. Despite being assessed as a high fall risk, fall mats were not implemented upon admission, and staff failed to ensure their consistent use even after they were added as a safety measure. This oversight contributed to the resident's repeated falls and injuries, highlighting a failure to provide necessary assistive devices and supervision.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility was found to have multiple deficiencies in its kitchen operations, which were not in accordance with professional standards for food service safety. Observations revealed that the walk-in freezer contained approximately twenty-five boxes of frozen foods stored on the floor and haphazardly stacked, which the Dietary Manager confirmed should have been placed on shelves. Additionally, a reach-in refrigerator contained a staff member's personal soda bottle, which was confirmed by the Dietary Manager as inappropriate for a refrigerator used for resident food items. Further observations highlighted significant cleanliness issues throughout the kitchen. The floor under the three-part sink was soiled with a dark brown substance, and the walls throughout the kitchen were soiled with substances of various colors. Equipment such as the commercial toaster, microwave, fryer, and dish sanitation machine were found to be soiled with crumbs, cooking oil, and residue from cleaning fluids. The juice dispenser wand was also soiled and leaking juice onto the floor. These conditions were confirmed by the Dietary Manager, who provided no explanation for the lack of cleanliness. Additional deficiencies included improper storage of food items, with boxes of frozen foods in the walk-in freezer not sealed, exposing them to freezer burn and contaminants. Two dietary aides were observed preparing meals without wearing required moustache/beard nets, which they admitted to forgetting. A tray with food items and a soiled knife was left out overnight, which was confirmed by the Dietary Manager as being left from the previous evening's snack preparation. These practices could potentially lead to illness due to foodborne pathogens, as noted in the facility's policy on kitchen sanitation.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse at the dumpster site, leading to an unsanitary environment. Observations revealed that two forty-gallon drums with loose lids were located behind the facility dumpsters, and used fryer oil had spilled from these drums onto the ground. Additionally, a large kitchen cooking pot full of used fryer oil was found without a lid behind the dumpsters. The area was also littered with assorted bits of paper, cardboard, and other refuse. During an interview, the Dietary Manager, who was new to the position, admitted to not knowing how to request the removal of the used fryer oil and confirmed that recent rain had caused the oil to overflow and spill. The Maintenance Director acknowledged that the spilled oil could pose a slip and fall hazard or a fire hazard. The facility's policy on maintaining garbage receptacles in a clean and sanitary manner was not adhered to.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for three residents who were unable to carry out activities of daily living. Resident #182 did not receive scheduled showers on two occasions, despite expressing her need for assistance due to weakness and a foul odor in her bathroom. The resident reported feeling neglected and was unable to shower independently due to staff restrictions. Interviews with staff revealed a misunderstanding about the resident's shower schedule and assistance provided by occupational therapy. Resident #183 was observed wearing a dirty t-shirt covered with residue and drool, as there were no clean shirts available. The CNAs responsible for his care were aware of the situation but did not take action to find a clean shirt from the lost and found or use a gown as an alternative. The CNAs mentioned that they were instructed not to use clothing protectors due to dignity concerns, and the LVN on duty was not informed about the issue. Resident #184 was found with unshaven facial hair, long eyebrows, and nose hair, indicating a lack of grooming. The resident, who had Alzheimer's Disease, required assistance with self-care tasks. Despite being scheduled for a shower and grooming, the necessary care was not provided. Interviews with staff confirmed that grooming tasks were part of the shower routine, but they were not completed. The DON acknowledged the resident's need for grooming and emphasized the importance of maintaining residents' hygiene.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 10% due to three errors out of 30 opportunities. This involved two residents, one of whom did not receive the correct insulin dosage due to a failure to perform a safety check on the insulin injection pen. The Licensed Vocational Nurse (LVN) administering the insulin was unaware of the manufacturer's guidelines, which require a safety test to ensure accurate dosing and proper pen function. Another incident involved a Medication Aide administering an antibiotic and nerve pain medication 40 minutes late to a resident. The medications were scheduled for 8:00 AM, but were given at 9:40 AM. The Medication Aide did not report the delay to the Director of Nursing (DON) and stated that the delay was due to accommodating residents' preferences for receiving medications after breakfast. The facility's policies on injectable insulin administration and timely medication administration were requested but not provided by the time of the report. The report references guidelines from the Institute for Safe Medication Practices and the National Library of Medicine, which emphasize the importance of timely medication administration and adherence to the 'five rights' of medication administration, including the 'right time'.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting four residents. One incident involved a Licensed Vocational Nurse (LVN) who did not perform a safety check on an insulin injection pen before administering insulin to a resident with diabetes. The LVN administered 14 units of insulin without checking the pen, which was exhausted, and then had to administer an additional 11 units to meet the prescribed dose. The LVN admitted to being unaware of the manufacturer's guidelines for performing a safety check prior to administration. Another issue was observed with a Medication Aide who administered medications late to three residents. The medications included oxcarbazepine and baclofen for a resident with bipolar disorder, ferrous sulfate and midodrine for a resident with anemia and hypotension, and carbidopa-levodopa for a resident with Parkinson's disease. The Medication Aide stated that the late administration was due to workload and residents' preferences to receive medications after breakfast. However, these preferences were not reported to the physician or the Director of Nursing (DON). The facility's policy on timely medication administration was not provided upon request, and the Medication Aide did not report the late administrations to her supervisor. The facility's administration stated that staff could accommodate residents' needs, and the Medication Aide was following policy regarding time-sensitive medications. However, the late administration of medications placed residents at risk of not receiving the therapeutic effects of their prescribed medications.
Ineffective Pest Control in Facility Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by an observation on May 1, 2024, at 1:20 p.m., where flies too numerous to count were found in and around the food preparation area, particularly near a box of fresh bananas. During an interview conducted at the same time, Dietary Aide Y confirmed the persistent presence of flies in the kitchen. A review of the pest control visit logs indicated that the pest control company visited the facility bimonthly. The facility's pest control policy, effective since February 2017, mandates maintaining an environment free of pests and rodents, including flies, through an effective pest control program.
Failure to Provide NOMNC to Discharged Residents
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) to three residents who were discharged from skilled services with Medicare benefits remaining. Specifically, Residents #235, #236, and #237 did not receive a NOMNC upon their discharge, which occurred on different dates in April 2024. This oversight was identified during a record review of the residents' closed records, which confirmed the absence of the required notices. Further investigation revealed that within the six months prior to the survey, twenty-three residents had been discharged from a Medicare-covered Part A stay with benefits remaining, yet only one had been issued a NOMNC. Interviews with the Business Office Manager (BOM) and the Administrator confirmed that the facility did not routinely issue NOMNCs to residents returning home after a Medicare-covered stay. The Administrator acknowledged the lack of a policy regarding the issuance of NOMNCs, which contributed to the deficiency.
Facility Fails to Address Persistent Odor Issue in Resident's Bathroom
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for Resident #182, who was admitted with Depression Disorder and Generalized Anxiety Disorder. Upon admission, Resident #182 reported a strong foul odor, similar to sulfur, emanating from her bathroom. Despite informing the staff about the issue, the smell persisted throughout her stay. The resident expressed discomfort and reluctance to use the bathroom facilities due to the odor, which was confirmed by observations and interviews conducted by the surveyor. Interviews with the maintenance staff (MS) and a certified nursing assistant (CNA) revealed that the sulfur smell was a known issue in the facility, attributed to dry p-traps in the plumbing lines. The MS had attempted to address the problem by running water down the drains and using enzymes, but the issue persisted. Plumbers were called to install back flaps to prevent the odor, but they did not have the necessary materials at the time of their visit. The facility's failure to resolve the odor issue in a timely manner compromised the resident's right to a safe and comfortable living environment.
Failure to Report and Investigate Unwitnessed Fall
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse and neglect, specifically in the case of a resident who experienced an unwitnessed fall resulting in a major head injury. The resident, who was severely cognitively impaired and incontinent, had a history of falls and was at risk for further incidents. Despite the severity of the injury, the Administrator did not report the incident to the appropriate state authorities within the required timeframe, nor did he investigate it according to facility policy. This failure to report and investigate was contrary to the facility's policy, which mandates immediate reporting of such incidents to ensure residents are not abused or neglected. The resident's medical history included a traumatic subarachnoid hemorrhage and unspecified dementia, which contributed to her confusion and inability to communicate about the fall. The post-fall assessment noted a laceration on the left side of her scalp, and she returned from the hospital with sutures. Interviews with the Administrator and Director of Nursing revealed a misunderstanding of the reporting requirements, as the Administrator initially believed a family member had witnessed the fall. However, it was later confirmed that there was no witness, and the resident was unable to provide details due to her cognitive impairment. The facility's policy clearly states that such incidents should be reported within two hours if they involve serious bodily injury, which was not adhered to in this case.
Failure to Report and Investigate Resident Fall
Penalty
Summary
The facility failed to report an alleged violation involving abuse or neglect within the required timeframe, specifically concerning a resident who experienced an unwitnessed fall resulting in a major head injury. The incident occurred when the resident, who was severely cognitively impaired and incontinent, fell while getting out of bed and sustained a laceration to the left side of the scalp. Despite the severity of the injury, the facility's administration did not report the incident to the Health and Human Services Commission (HHSC) within the mandated two-hour window, as required by regulation. The facility's policy on abuse and neglect mandates immediate reporting and investigation of such incidents to prevent further harm. However, the Administrator (ADM) failed to adhere to this policy, mistakenly believing a family member had witnessed the fall. Upon realizing there was no witness and the resident was unable to communicate due to confusion, the ADM acknowledged the event as reportable but did not take the necessary steps to report or investigate it. This oversight could potentially affect any resident and contribute to further abuse and neglect.
Failure to Obtain Physician Orders for Immediate Care
Penalty
Summary
The facility failed to obtain physician orders for the immediate care of two residents upon their admission. Resident #183 was admitted with several serious diagnoses, including nonromantic intracranial hemorrhage and hydrocephalus, and was found to have cradle cap, a condition characterized by brownish flakes on the scalp. Despite the visible condition and a family member's concern about the resident's hygiene, the nursing staff did not obtain a physician's order for treatment of the cradle cap. This oversight was confirmed during an observation and interview with an LVN, who noted the absence of a treatment order in the resident's records. Similarly, Resident #185 was admitted with traumatic subarachnoid hemorrhage and unspecified dementia. Observations revealed the use of side rails on the resident's bed, which were intended to serve as enablers to promote independence. However, the facility failed to secure a physician's order for the use of these side rails, as confirmed by a review of the resident's consolidated physician orders. The DON acknowledged the importance of having physician orders for any treatment or adaptive equipment used for residents, highlighting the deficiency in obtaining necessary orders for the residents' care.
Failure to Conduct Significant Change MDS Assessment
Penalty
Summary
The facility failed to conduct a significant change Minimum Data Set (MDS) assessment for a resident who experienced a notable change in condition. The resident, who was initially admitted with diagnoses including heart failure and acute kidney failure, was readmitted from the hospital with a new diagnosis of encephalopathy and hyponatremia. Despite these significant changes, the MDS staff did not complete a significant change MDS assessment within the required 14-day period after the resident's return from the hospital. The resident's condition included a new diagnosis of encephalopathy, which was not present in the initial admission MDS assessment but was noted in a subsequent 5-day MDS assessment. The resident was also placed on a fluid restriction, which was not adhered to by the family representative. The facility's Regional Nurse Consultant and MDS Coordinator initially believed the resident did not qualify for a significant change assessment, but later acknowledged that the resident's condition met the criteria for a significant change as outlined in the RAI Version 3.0 Manual. This oversight could potentially affect the care and services provided to the resident.
Failure to Prevent Pressure Ulcers in a Resident
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for a resident, leading to a deficiency. The resident, who was admitted with severe cognitive impairment and was dependent on staff for all activities of daily living, was identified as being at risk for developing pressure ulcers. Despite recommendations from a wound specialist to use a pressure-relieving boot and off-load the resident's heels, observations on multiple occasions revealed that the resident's feet were not being off-loaded, and the recommended boot was not applied. Interviews with nursing staff confirmed the lack of adherence to the care plan, as they acknowledged the resident's risk for skin breakdown and the absence of necessary interventions. The resident's care plan, initiated shortly after admission, highlighted the need for frequent repositioning and heel off-loading to prevent skin injury. However, during observations, the resident was found lying in bed without the recommended pressure-relieving boot or any alternative measures, such as pillows, to off-load the feet. Interviews with the Director of Nursing and other staff members revealed that the boot might have been taken for washing by a family member, but no alternative measures were implemented in its absence. This lack of compliance with the care plan and professional standards of practice contributed to the development of a pressure sore on the resident's buttock, highlighting a failure in the facility's pressure ulcer prevention program.
Improper Catheter Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with an indwelling urinary catheter, which could prevent urinary tract infections. During an observation, a CNA lifted the resident's urine collection bag above the bladder while providing catheter care, contrary to proper catheter maintenance techniques. This action was observed during a joint care session with an LVN, where the urine collection bag was raised approximately six inches above the resident's body and bladder during repositioning. The resident, an elderly male, was admitted with diagnoses including urinary retention and a urinary tract infection, and had been prescribed an indwelling urinary catheter. The care plan indicated a need for catheter care every shift and monitoring for infections. Despite this, the facility's policy did not include guidelines for maintaining the urine collection bag below the bladder level, which is a standard practice to prevent infections. Interviews with the CNA and LVN revealed a lack of awareness of the proper procedure, and the facility's administration acknowledged the risk of urine backflow and infections from improper handling of the catheter bag.
Medication Security and Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and only accessible to authorized personnel. On one occasion, a nurse left a medication cart unattended and unlocked in a hallway, which was observed by staff and residents. The nurse acknowledged the oversight and locked the cart upon returning. This incident was confirmed during an interview with the Administrator and the Director of Nursing, who stated that medication carts should be locked when unattended. Additionally, a resident was found to have medicated eye drops and nasal spray unsecured at her bedside. The resident expressed a lack of confidence in the nursing staff's ability to administer her eye drops on time, which she believed could lead to blindness if not administered properly. Staff members, including a CNA and an LVN, observed the medications at the resident's bedside but were unaware if the resident was permitted to self-administer them. The facility's policy requires that medications not be stored at a resident's bedside without an assessment for safe self-administration and patient education.
Failure to Notify Physicians of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of abnormal laboratory results for two residents, leading to a deficiency in care. Resident #9, who had a history of heart failure, acute kidney failure, hyponatremia, and encephalopathy, had abnormal lab results on two occasions that were not reported to the physician. These results included low sodium levels, high glucose, low red blood cell count, and low hemoglobin, among others. Despite the facility's policy to report such findings, there was no documentation of these abnormal results being communicated to the physician over a six-month period. Similarly, Resident #30, who was admitted with hyperkalemia, vitamin D deficiency, and skin infections, also had abnormal lab results that were not reported. The resident's lab results showed high hematocrit, high red blood cell distribution width, and low mean corpuscular hemoglobin concentration. Like Resident #9, there was no evidence that these results were communicated to the physician, which is contrary to the facility's procedures for handling abnormal lab findings. Interviews with the facility's administration and nursing staff revealed that the standard procedure was to fax lab results to the physician, call them, and document the communication in the resident's progress notes. However, this process was not followed for the residents in question. The facility's policy emphasizes the importance of timely and accurate reporting of lab results to ensure appropriate intervention, which was not adhered to in these cases.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodates the preferences of a resident, specifically Resident #70, who has an intense dislike of cheese and dairy products. Despite this preference being documented on the resident's meal ticket, the resident was served a cheese omelet for breakfast. This oversight was observed on May 1, 2024, at 10:03 a.m., and was confirmed through an interview with the resident, who expressed that consuming cheese or dairy causes nausea. Resident #70 has a medical history that includes unspecified severe protein-calorie malnutrition, muscle wasting and atrophy, and an anxiety disorder. The resident's care plan, revised in April 2024, highlights the risk for nutritional deficits and dehydration due to chronic comorbidities, including heart and kidney disease. The care plan specifies the need to provide diet and fluids according to the resident's preferences to ensure adequate intake. Despite these documented needs and preferences, the dietary staff failed to adhere to the resident's meal ticket instructions, leading to the deficiency.
Deficiency in Food Storage Policy for Resident-Provided Items
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, which resulted in a deficiency. During an observation, an opened bottle of prune juice was found on Resident #62's bedside table. The bottle was unrefrigerated, unlabeled, and undated, despite the manufacturer's label indicating that it should be refrigerated after opening. Resident #62 confirmed that her niece brings the prune juice to her and that she stores it on her bedside table due to the absence of a refrigerator. The facility's policy on dietary services, revised in January 2023, states that the community provides proper storage of foods provided by family members to ensure safe and sanitary storage, handling, and consumption.
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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