The Villa At Mountain View
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 2918 Duncanville Rd, Dallas, Texas 75211
- CMS Provider Number
- 675783
- Inspections on file
- 44
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at The Villa At Mountain View during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment, as evidenced by strong odors from large trash bins in multiple halls and the use of strong-scented sprays by staff to mask these odors, which could affect residents with respiratory issues. Additionally, mechanical lifts and a shower bed were left unlocked and stored in hallways, contrary to facility policy and life safety guidance, creating potential hazards for residents.
Staff failed to follow enhanced barrier precautions by not wearing required PPE such as gowns and gloves during high-contact care activities, including repositioning, perineal care, handling soiled linens, and G-tube care for a resident with severe cognitive impairment and a gastrostomy tube. Despite EBP signage and available PPE, staff did not consistently adhere to infection control protocols, and hand hygiene was not always performed after care.
Five residents with significant physical and/or cognitive impairments were found to have call lights out of reach, including on the floor or behind furniture, despite care plans and facility policy requiring accessibility. Staff interviews confirmed the expectation that call lights be within reach at all times, but this was not consistently followed.
A nurse left a computer tablet displaying a resident's EMAR and insulin administration details unattended on a medication cart for several minutes, with the screen visible to others nearby. The resident had complex medical needs and no cognitive impairment. Facility policy requires confidentiality of resident information and that computer screens be locked when unattended, but this was not followed in this instance.
A medication cart was left unattended and unlocked in a resident hallway, with two residents present in their room nearby. An LVN had just administered medication and left the cart accessible while attempting to speak with a doctor, contrary to facility policy requiring medication carts to be locked when not in use. The incident was observed by a surveyor and confirmed through staff interviews and policy review.
A resident with severe cognitive impairment and a history of mood disorders was able to leave the facility unsupervised through a back door, despite being care planned for wandering risk and requiring a wander guard bracelet. The resident was found on the street near a busy highway with a skin tear, and staff interviews revealed gaps in awareness and recall of the incident. The deficiency involved a failure to provide adequate supervision and ensure the effectiveness of assistance devices to prevent elopement.
A resident with severe cognitive impairment and a history of malnutrition was served a pureed meal instead of the prescribed regular ground diet, as indicated on the meal ticket. Staff interviews and observations confirmed the error occurred due to a lack of proper verification of the meal texture before service, despite established procedures and policies.
A resident with severe cognitive impairment and multiple pressure ulcers had weekly labs ordered to be sent to her infectious disease physician. Although the labs were drawn, the facility did not ensure the results were sent to the physician as ordered, and the physician's clinic reported not receiving the results despite repeated requests. Facility staff could not confirm or document that the labs were sent, which was not in accordance with facility policy.
A resident with a history of multiple mental health diagnoses and severe cognitive impairment received a new diagnosis of schizoaffective disorder, bipolar type, but was not referred for a new PASRR assessment as required. Staff interviews revealed confusion about the process, and documentation was incomplete, resulting in the resident not being evaluated for PASRR services.
A resident with multiple medical conditions and complex medication needs did not have a comprehensive care plan developed and implemented as required. The care plan lacked measurable objectives and timeframes for diabetes management, use of antidepressants, opioid use, insulin administration, and ADL care, despite these needs being identified in the assessment and physician orders. Facility staff confirmed the care plan was incomplete and not consistent with policy requirements.
A resident with a feeding tube did not receive enteral nutrition and water flushes according to physician orders, as nursing staff set the feeding pump to incorrect rates and failed to verify updated orders. Staff interviews revealed a lack of awareness of order changes and inconsistent adherence to facility policy requiring verification of feeding and flush rates.
A resident with end-stage renal disease and other comorbidities did not have dialysis communication forms fully completed on several occasions, with only pre-dialysis information documented and treatment details missing. Nursing staff reported challenges in obtaining completed forms from the dialysis center, and oversight failed to identify the incomplete documentation, despite facility policy requiring full completion of these records.
The facility did not ensure accurate narcotic logs and medication administration records for two residents, resulting in discrepancies between the recorded and actual counts of controlled medications. An LPN failed to log one administration and signed off for a dose that was not given, leading to mismatched records and delayed medication for a resident. The DON confirmed that staff are required to document and reconcile narcotic counts according to facility policy.
A nurse crushed and mixed all prescribed medications together in one cup of pudding and administered them to a resident with severe cognitive impairment, without a physician's order to do so. This resulted in a medication error rate of 10% after 30 opportunities, as confirmed by observation, interviews, and record review. Facility leadership and training materials indicated that a physician's order was required for crushing and mixing medications, but no such order was present for this resident.
A resident with severe cognitive impairment and a history of mental health conditions eloped from the facility and was found outside by staff with a skin tear. Although the incident was documented internally and the resident was treated, the facility did not report the elopement and injury to the state agency as required by regulation. Staff interviews and record reviews confirmed the lack of external reporting despite existing policies and staff training on timely reporting of such events.
A resident with multiple complex medical conditions experienced an unwitnessed fall resulting in back pain and abnormal x-ray findings. Nursing staff failed to immediately notify the responsible party, instead contacting a different family member not listed as the responsible party. The responsible party was not informed of the fall or hospital transfer in a timely manner, despite facility policy requiring such notification.
Nursing staff failed to notify the correct responsible party after a resident experienced an unwitnessed fall, abnormal x-ray findings, and a hospital transfer, instead communicating with a non-designated family member. This resulted in the actual responsible party not being promptly informed about significant changes in the resident's condition, in violation of privacy and confidentiality requirements.
A resident with moderate cognitive impairment and multiple complex medical conditions did not have a comprehensive ADL care plan developed or implemented, despite being dependent on staff for most daily activities and at risk for falls and pressure injuries. The omission was confirmed through record review and staff interviews, revealing gaps in care planning and communication among facility staff.
A resident with complex medical needs and high risk for pressure injuries developed a sacral wound and a new left heel wound after staff failed to provide timely incontinence care and did not consistently communicate or document care needs. Inadequate assessment, incomplete care planning, and reliance on incorrect information led to lapses in care, resulting in the development and progression of pressure ulcers.
A resident with multiple complex conditions and a newly diagnosed sacral pressure ulcer did not have this diagnosis added to their EMR profile by the responsible MDS staff, resulting in incomplete medical records. The absence of a designated backup for updating diagnoses and the lack of a written medical records policy contributed to the deficiency.
Two residents eloped from the facility without staff awareness, highlighting a failure in supervision and monitoring. One resident, with a history of cognitive impairment, removed her Wanderguard and left the facility. Both residents were not identified as elopement risks, and their absence was not discovered until the next shift. Staff familiarity with the residents' routines may have contributed to the oversight.
The facility's kitchen failed to meet professional food safety standards, with unlabeled, undated, and unsealed food items found in the refrigerator, freezer, and pantry. Additionally, a trash can without a lid was observed in the food prep area, and lighter fluid was improperly stored in the dry food storage area. Staff interviews revealed training on proper procedures, but compliance issues persisted, posing contamination risks.
A facility failed to update a resident's care plan to reflect their elopement risk and use of a wanderguard, despite the resident's history of elopement. Staff interviews revealed confusion over responsibility for care plan updates, and the Administrator downplayed the importance of the care plan. The facility's policy requires care plans to be updated for identified risks, which was not followed, potentially placing the resident at risk.
A resident with multiple health issues attempted to elope by removing her Wanderguard, but the LTC facility failed to document the incident as required by policy. The DON was unaware of the incident, and the Administrator believed a report was unnecessary since the resident did not leave the premises.
The facility failed to ensure that sharps disposal bins on nurse medication and treatment carts were kept below the full line, posing a risk of exposure to contaminated sharps. LVNs responsible for these carts acknowledged the hazard, and interviews confirmed that nursing staff were expected to change the bins when full. The facility's policy required replacement of containers when 75% to 80% full, but this was not adhered to.
Two residents missed their dialysis appointments due to transportation issues, and the facility failed to notify their physicians or document the missed appointments. This lack of communication and documentation could have led to serious health risks. The facility's policy requires notifying the physician of any changes in condition, but this was not followed.
Two residents missed their dialysis appointments due to a failure in arranging alternate transportation after the contracted service canceled. The facility's receptionist did not communicate the cancellation, and the facility van was unavailable. Despite the oversight, both residents remained stable, but the incident highlighted deficiencies in the facility's processes.
The facility failed to maintain a clean restroom for two residents and did not ensure functional door handles for two other residents. One resident's restroom had a dried black substance resembling fecal matter, and two residents had a missing door lever, making it difficult to open the door from the inside.
Two residents in a LTC facility did not receive timely incontinent care, leading to feelings of neglect and potential health issues. One resident, with moderate cognitive impairment, was left unchanged for several hours despite pressing the call light. Another resident, with no cognitive impairment but physical limitations, experienced similar delays and developed a rash. Staffing issues and inadequate response to call lights were identified as contributing factors.
Failure to Maintain Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for residents across five of six halls. Surveyors observed multiple 32-gallon trash bins emitting strong odors of urine and feces in several hallways, which led to complaints from residents about the smell. In response to these odors, a CNA was seen spraying a strong-scented perfume down one hallway, and another staff member reported using Febreze. The use of perfume was acknowledged by the Treatment Nurse as potentially harmful to residents with respiratory issues. Staff interviews confirmed that the odors were a recurring issue and that scented sprays were used in an attempt to mask them. Additionally, mechanical lifts and a shower bed were observed unlocked and stored in hallways on multiple occasions. The administrator stated that the equipment could not be locked due to life safety requirements regarding egress pathways, but communication from the Life Safety Director clarified that the issue was not about locking the equipment, but rather that such equipment should not be stored in the egress pathways at all. Facility policy indicated that accessible hazards, such as unlocked equipment, should be secured to prevent injury, but this was not followed, resulting in unsafe conditions for residents.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff not following enhanced barrier precautions (EBP) for a resident requiring such measures. The resident in question was a male with severe cognitive impairment, total dependence for activities of daily living, and a gastrostomy tube, who was placed on EBP due to the presence of an indwelling medical device. Facility policy and CDC guidance required staff to wear gowns and gloves during high-contact care activities for residents on EBP. On several occasions, staff members, including an LVN and CNAs, provided high-contact care such as repositioning, perineal care, handling soiled linens, and G-tube care to the resident without donning the required personal protective equipment (PPE) such as gowns and gloves. Observations by the surveyor confirmed that staff failed to use appropriate PPE during these activities, despite EBP signage being posted above the resident's bed and PPE supplies being available in the room. Additionally, hand hygiene protocols were not consistently followed, as one CNA was observed not washing hands or using hand sanitizer after disposing of trash. Interviews with staff, including the wound care nurse, CNAs, LVN, ADON, DON, and the Medical Director, confirmed that they were aware of the EBP requirements and the need for PPE during high-contact care. However, despite this knowledge and the presence of visual cues, staff did not consistently adhere to infection control procedures. The facility had 23 residents on EBP at the time, and the failure to follow established protocols was directly observed and corroborated by staff interviews and record reviews.
Failure to Ensure Call Light Accessibility for Multiple Residents
Penalty
Summary
The facility failed to ensure that the call light system was accessible to five residents who required varying levels of assistance and were at risk for falls. Observations on a specific date revealed that the call lights in the rooms of these residents were not within their reach. In several cases, the call lights were found on the floor, under beds, behind side tables, or otherwise out of reach, despite care plans specifying that call lights should be accessible to the residents at all times. The residents involved had significant medical conditions, including muscle weakness, hemiplegia, hemiparesis, and abnormalities of gait. Some residents had severe cognitive impairments, as indicated by low BIMS scores, and required maximal or moderate assistance with activities of daily living such as dressing, bed mobility, and transfers. During interviews and observations, some residents were unable to locate their call lights or did not respond when asked about them, while others confirmed that their call lights had been out of reach for some time. Staff interviews confirmed that it was the responsibility of all staff members, including CNAs, LVNs, the ADON, and the DON, to ensure that call lights were within reach of residents at all times. Staff acknowledged that call lights are essential for residents to request assistance or alert staff in case of need. Facility policy and in-service training materials also specified that call lights should always be within residents' reach, but this expectation was not met during the observations documented in the report.
Unattended Computer Screen Exposes Resident Medical Information
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) left a computer tablet displaying a resident's electronic medication administration record (EMAR) unattended on top of a medication cart. The screen was visible for approximately three minutes without any staff present, during which time it displayed the resident's picture and details of a recent insulin administration. The medication cart was positioned in the doorway of a resident's room, with other residents nearby and staff observed at a distance. The resident whose information was exposed had multiple complex medical conditions, including cirrhosis, renal insufficiency, viral hepatitis, diabetes mellitus, asthma, and respiratory failure. The resident required assistance with activities of daily living and had no cognitive impairment, as indicated by a BIMS score of 15. The EMAR on the unattended computer showed specific details about the resident's insulin administration, including the dosage and timing, which could have been viewed by other residents or visitors. Interviews and observations confirmed that the LVN left the computer unlocked while attempting to locate a physician, and the facility's policies require that resident information be kept confidential and computer screens locked when unattended. The incident was identified during a surveyor's observation, and the LVN acknowledged that leaving the screen unlocked was a violation of HIPAA and facility policy.
Unattended and Unlocked Medication Cart Left Accessible in Resident Hall
Penalty
Summary
A deficiency occurred when a medication cart was left unattended and unlocked in the doorway of a resident room on Hall 500. The cart's lock was visibly disengaged, and no staff were present in the immediate area, while two residents were in their room watching TV. The incident was observed by a surveyor, who noted that the cart was accessible to anyone passing by. The nurse responsible for the cart, an LVN, returned to the cart a few minutes later and acknowledged that she had left it unlocked while attempting to speak with a doctor. She confirmed that the cart could have been accessed by unauthorized individuals during her absence and admitted that it should have been locked. The facility's policy requires all drugs and biologicals to be stored in locked compartments when not in use, and medication carts are not to be left unattended if open or accessible. The LVN stated she had just administered diabetic medication to a resident prior to leaving the cart. The incident was confirmed through observation, staff interviews, and review of facility policy and employee records. The administrator and DON were made aware of the incident and confirmed that leaving medication carts unlocked is against facility policy.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Monitoring
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of depression and bipolar disorder was able to elope from the facility through the back door. The resident, who utilized a wheelchair and had a BIMS score indicating severe cognitive impairment, was found on the street attempting to go to a gas station across from the facility, which is located near a busy highway. The resident sustained a skin tear to his arm during the incident. Documentation shows that the resident's care plan identified him as being at risk for wandering and required the use of a wander guard bracelet, with interventions including monitoring the bracelet's placement and function, and observing the resident's location each shift. Despite these interventions being documented, the resident was able to leave the facility unsupervised. The elopement risk assessments completed prior to the incident did not indicate imminent risk, and there were no additional elopement risk assessments found in the resident's health chart. Staff interviews revealed that while staff were generally aware of elopement protocols and the use of wander guard systems, several staff members were unaware of the specific incident or did not recall details about the resident's elopement. The door through which the resident exited was equipped with a wander guard alarm system, which was observed to be functional at the time of the survey, but it is unclear from the report how the resident was able to exit undetected. The incident was documented in clinical notes and an accident/incident report, which described the resident's elopement and subsequent return to the facility. The resident's family was notified, and the event was reported by staff. The deficiency centers on the facility's failure to provide adequate supervision and ensure the effectiveness of assistance devices to prevent the resident's elopement, as required by the resident's care plan and facility policy.
Failure to Provide Prescribed Diet Texture to Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of protein-calorie malnutrition, hypertension, depression, and bipolar disorder was not provided with the prescribed regular ground diet. Instead, the resident was served a pureed meal, despite the meal ticket indicating the need for a regular ground texture. The resident expressed dissatisfaction with receiving pureed foods, stating that he did not want to eat when served the incorrect texture. Observations confirmed that the resident was given a pureed meal, and staff interviews revealed that the error was due to a failure to verify the correct food texture as indicated on the meal ticket. Multiple staff members, including Central Supply, the RD, the Dietary Manager, and the DON, acknowledged that the resident should have received the regular ground diet as prescribed. The process for meal verification involved several staff, but the error was not caught before the meal was served. The facility's policy required diets to be determined according to residents' needs and preferences, but this was not followed in this instance, resulting in the resident receiving the wrong food consistency.
Failure to Promptly Notify Physician of Lab Results
Penalty
Summary
The facility failed to promptly notify the infectious disease physician of laboratory results for one resident who required weekly lab monitoring as ordered by the physician. The resident, a female with severe cognitive impairment, diabetes, anxiety disorder, and multiple pressure ulcers including a stage 4 ulcer, was admitted with orders for weekly CRP, BMP, and CBC labs to be faxed to her infectious disease doctor. Although the facility obtained the required labs on three separate occasions, there was no documentation or confirmation that these results were sent to the physician as ordered. Interviews with the resident's family and the infectious disease doctor's clinic revealed that the clinic did not receive the lab results despite multiple requests and follow-up calls to the facility. The clinic only received one set of labs after the resident was discharged. Facility staff, including the ADON and DON, could not confirm or provide documentation that the labs were sent as required. This failure was not in accordance with the facility's own policy, which requires staff to document when, how, and to whom lab results are provided.
Failure to Coordinate PASRR Assessment After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for one resident who was reviewed for PASRR assessments. The resident, a male with a history of depression disorder, anxiety disorder, psychotic disorder, and non-Alzheimer's dementia, was admitted with severe cognitive impairment. He received a new diagnosis of schizoaffective disorder, bipolar type, but the facility did not refer him to the appropriate state-designated mental health authority for review as required. The resident's PASRR Level 1 screening, completed previously, did not indicate a mental illness, and a subsequent 1012 Form listed a primary diagnosis of dementia, but sections of the form were incomplete. Interviews with facility staff revealed confusion regarding the need for a new PASRR evaluation following the new diagnosis. The Resident Care Coordinator (RCC) initially believed the dementia diagnosis on the 1012 Form overrode the new mental health diagnosis, but later acknowledged the form was not completed correctly and that a new PASRR Level 1 or 1012 Form should have been completed. The Director of Nursing (DON) confirmed that a new PASRR evaluation should be done when a new diagnosis is given. The facility's admission policy requires all new admissions and readmissions to be screened for mental disorders per the PASRR process.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions. The resident, a cognitively intact female, was admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, hypertension, diabetes mellitus, muscle weakness, and septicemia. Her assessment indicated she required substantial to maximal assistance with activities of daily living (ADLs) and was receiving several medications, including antidepressants, antibiotics, diuretics, hypoglycemics, and opioids. Upon review, the resident's care plan lacked measurable objectives and timeframes for several critical areas. While the care plan addressed code status and fall risk with some goals and interventions, it did not include any goals or interventions for diabetes management, use of antidepressant medication, opioid use, insulin administration, or ADL care. Physician orders documented the administration of multiple medications, including insulin and antidepressants, but these were not reflected in the care plan as required. Interviews with facility staff, including the ADON and DON, confirmed that the care plan was incomplete and did not address all areas triggered by the resident's assessment. The ADON acknowledged responsibility for ensuring the care plan was accurate and complete, and both the ADON and DON recognized that incomplete care plans could result in staff not providing the necessary care. Facility policy required comprehensive care plans with measurable objectives and timetables to be developed within seven days of the assessment, but this was not followed in this case.
Failure to Follow Physician Orders for Enteral Feeding Administration
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was provided with the appropriate treatment and services as ordered by the physician. Specifically, the resident, who had a history of dysphagia and moderate cognitive impairment, had physician orders for her feeding tube to be flushed with 50 mL of water every hour and to receive Jevity 1.2 at a rate of 55 mL/hr. However, observations and interviews revealed that the feeding pump was set to deliver Jevity 1.2 at 65 mL/hr and water flushes at 35 mL/hr, which did not match the physician's orders. Nursing staff admitted to not checking the current orders before administering the feedings and water flushes, and were unaware that the orders had been changed. Further interviews with facility staff, including the ADON and DON, confirmed that there was an expectation for nurses to verify and follow physician and dietitian orders, but this was not consistently done. The ADON acknowledged responsibility for updating orders in the electronic record and monitoring compliance, but had not checked the resident's pump settings since the orders were changed. Training records indicated that not all staff responsible for the resident's care had attended recent in-service training on enteral feeding administration. The facility's policy required staff to check enteral nutrition labels and administration rates against orders, but this was not followed in practice.
Incomplete Dialysis Communication Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received services consistent with professional standards, the care plan, and the resident's preferences. Specifically, the dialysis communication forms for the resident were not completed with the necessary treatment information on multiple occasions. On the dates reviewed, only the pre-dialysis information was filled out, while the sections for dialysis treatment information were either left blank or marked as not applicable. The resident in question was an older female with moderate cognitive impairment and multiple active diagnoses, including renal insufficiency, renal failure or end-stage renal disease, heart failure, and respiratory failure. She was admitted to the facility and had physician's orders and a care plan indicating the need for regular dialysis. The process required the completion of pre- and post-dialysis sections on a communication form, with the expectation that the dialysis center would fill out the treatment information and return the form with the resident. Interviews with nursing staff revealed that the pre-dialysis section was completed by the morning nurse, and the afternoon nurse was responsible for ensuring the post-dialysis information was recorded. However, the dialysis center often did not return the completed forms, and the afternoon nurse sometimes had difficulty obtaining the necessary information. The ADON, responsible for oversight, was unaware that the forms were incomplete, and the facility's policy required all sections of the communication record to be completed and filed.
Failure to Maintain Accurate Narcotic Logs and Medication Administration Records
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring accurate narcotic logs and medication administration records for two residents on the 500 Hall medication cart. For one resident with a history of hip and knee replacement and moderately impaired cognition, the narcotic administration record for Acetaminophen-Codeine showed a discrepancy of one pill between the log and the blister pack. The medication was last administered in the morning, but the count did not match the record. For another resident with pain and intact cognition, the narcotic administration record for hydrocodone-acetaminophen also showed a one-pill discrepancy, with the log indicating one less pill than the blister pack. The medication was signed off as given, but the resident reported not receiving it until later when the nurse realized the omission. Interviews with the nurse responsible revealed she was unaware of the discrepancies and admitted to forgetting to log one administration and to signing off for a medication that was not actually given. The nurse acknowledged the importance of reconciling counts and logging medications immediately after administration, as per facility policy and training. The DON confirmed that staff are expected to document administration on both the medication administration record and the narcotic log, and that counts should be reconciled at each shift change. Review of facility policy and training materials supported these expectations.
Medication Error Rate Exceeds 5% Due to Improper Crushing and Mixing of Medications
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) crushed and mixed all of a resident's prescribed medications together in one cup of pudding and administered them without a physician's order to do so. The medications included bismuth/metronidazole/tetracycline capsules, Renal-Vite, and vitamin C. The LVN was observed preparing and administering the medications in this manner, and during an interview, admitted to not being aware that a physician's order was required to crush and mix the medications. The LVN also stated that she had been crushing and mixing the medications for the resident since admission without verifying the need for an order. The resident involved was a male with severe cognitive impairment, as indicated by a BIMS score of 5, and had diagnoses including pneumonia and chronic kidney disease. Review of the resident's records confirmed there was no physician order to crush and mix the medications. Facility leadership, including the ADON and DON, confirmed that staff are expected to have physician orders for crushing and mixing medications, and that the standing order for crushing was not present on the resident's medication administration record. The facility's training materials also specified that medications should not be crushed without an appropriate order.
Failure to Timely Report Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the appropriate authorities as required by regulation. Specifically, the facility did not report an incident in which a resident with severe cognitive impairment and multiple mental health diagnoses eloped from the facility. The resident, who was assessed as being at risk for wandering and required a wander guard bracelet, was found outside the facility on the street by a staff member. Upon return, the resident was noted to have a skin tear on his left arm, which was treated by nursing staff. Documentation in the resident's clinical notes and an accident/incident report confirmed the elopement and injury. However, a review of the Texas Unified Licensure Information Portal showed that no incident report regarding the elopement was submitted to the state agency. Interviews with current and former staff, including the DON and Administrator, revealed that the incident was not reported to the state, and there was uncertainty among staff about whether the event was reportable. The facility's own policies required immediate reporting of such incidents to regulatory authorities, but this protocol was not followed in this case. The failure to report the elopement and associated injury was identified through observation, interview, and record review. The deficiency was further substantiated by the lack of documentation in state reporting systems and by staff interviews indicating a lack of awareness or recall of the incident. The facility's in-service training records showed that staff had been trained on abuse prevention and timely reporting, yet the required reporting procedures were not implemented for this event.
Failure to Notify Responsible Party of Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to immediately notify the resident's responsible party following an unwitnessed fall that resulted in injury and required physician intervention, as well as during the subsequent transfer of the resident to the hospital. Specifically, after the resident was found on the floor with complaints of back pain, the nurse on duty attempted to call the responsible party but only left a voicemail and did not make further attempts to reach them or ensure the message was received. Documentation indicated that the responsible party was notified, but interviews revealed that the responsible party did not receive timely information about the fall or the hospital transfer. Further review showed that another nurse failed to notify the responsible party about the resident's transfer to the hospital after abnormal x-ray findings. Instead, communication was made with a family member who was not listed as the responsible party on the resident's face sheet. This led to confusion and a delay in the responsible party being informed about the resident's condition and hospital transfer. The responsible party only learned of the events after being contacted by the other family member and upon visiting the facility in person. The resident involved had multiple complex medical conditions, including atrial fibrillation, diabetes, and a history of falls, and was dependent on staff for most activities of daily living. The facility's own policy required immediate notification of the responsible party in the event of a significant change in condition, such as a fall or hospital transfer. However, staff failed to follow this policy, resulting in a lack of timely communication with the appropriate family member regarding the resident's fall, abnormal x-ray results, and transfer to the hospital.
Failure to Notify Responsible Party and Maintain Confidentiality of Medical Records
Penalty
Summary
The facility failed to ensure the right to personal privacy and confidentiality of personal and medical records for one resident, as required. Specifically, nursing staff did not notify the correct responsible party (RP) listed on the resident's face sheet following an unwitnessed fall and subsequent transfer to the hospital. Instead, staff communicated with a family member who was not designated as the RP, resulting in the actual RP not being informed in a timely manner about the resident's fall, abnormal x-ray findings, and hospital transfer. The resident involved was an elderly male with multiple complex medical conditions, including atrial fibrillation, hypertension, diabetes, metabolic encephalopathy, and a history of falls. He was cognitively impaired, dependent on staff for most activities of daily living, and at risk for pressure injuries. After an unwitnessed fall, the resident complained of back pain, and x-rays revealed abnormal findings. Orders were obtained for further evaluation, and the resident was sent to the hospital. Documentation and interviews confirmed that the RP listed on the face sheet was not notified promptly; instead, another family member was contacted and provided with information about the resident's condition and care. Interviews with staff and the RP confirmed that the RP did not receive notification about the fall or hospital transfer until much later, and only after he sought information himself. Nursing staff acknowledged confusion regarding which family member to contact and admitted to not verifying the correct RP before disclosing information. The documentation also showed inconsistencies in notification records, and the responsible staff did not follow established protocols for ensuring the correct party was informed of significant changes in the resident's condition.
Failure to Develop and Implement Comprehensive ADL Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident, as required by regulatory standards. Specifically, the care plan did not include measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The care plan was missing critical information regarding the level of assistance needed for activities of daily living (ADLs) such as dressing, toileting, bed mobility, and transfers. The resident in question was an older male with moderate cognitive impairment, multiple complex medical diagnoses, and a history of falls. He was dependent on staff for most ADLs, including toileting, showering, and dressing, and was at risk for pressure injuries. Despite these needs being identified in his admission MDS assessment, the corresponding ADL care plan was not completed or available in the electronic medical record at the time of review. This omission was confirmed during interviews with the MDS Coordinator, who acknowledged the absence of the care plan and the potential for safety issues as a result. Further interviews with facility staff, including the Administrator and Director of Rehabilitation, revealed a lack of awareness regarding the missing care plan and inconsistencies in communication and responsibility for care plan development. The facility's own policy requires that care plans be individualized, comprehensive, and updated as resident conditions change, but this process was not followed for the resident, resulting in incomplete guidance for staff on how to meet the resident's needs.
Failure to Prevent and Manage Pressure Ulcers Due to Inadequate Incontinence Care and Communication
Penalty
Summary
A resident with multiple complex medical conditions, including atrial fibrillation, diabetes, and cognitive impairment, was admitted to the facility and assessed as being at risk for pressure injuries. Upon admission, initial nursing assessments documented intact skin with no wounds or discoloration. However, within days, a treatment nurse identified purplish discoloration on the resident's sacrum, and wound care was initiated. Documentation and interviews revealed inconsistencies regarding whether the sacral wound was present on admission or developed shortly after, with some staff stating the wound was not present at admission and others indicating it was. The resident was dependent on staff for activities of daily living, including toileting and incontinence care, and was always incontinent of bowel and occasionally of bladder. On one occasion, a CNA failed to provide timely incontinent care, leaving the resident soiled for an extended period. This lapse was observed by the resident's family member, who reported the resident's bed and clothing were saturated with feces and urine. The CNA later admitted to not checking the resident's care plan and relying on incorrect information from another CNA regarding the resident's continence status. The nurse on duty was made aware of the situation and ensured the resident was changed, but the incident was not promptly escalated to facility leadership. Subsequently, the resident developed an open sacral wound and later a new left heel wound, both of which were documented as acquired in-house. The care plan did not initially address all aspects of the resident's ADL care, and there were gaps in communication and documentation regarding wound care and skin assessments. The failure to provide consistent and timely incontinence care, along with inadequate communication among staff regarding the resident's needs and care assignments, contributed to the development and progression of pressure injuries.
Incomplete Medical Record Documentation for Pressure Ulcer Diagnosis
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically by not adding a new diagnosis of a sacral pressure ulcer to the resident's electronic medical record (EMR) profile. The resident, an older male with multiple complex medical conditions including atrial fibrillation, hypertension, diabetes, and a history of falls, was assessed as being at risk for pressure injuries and had at least one pressure injury documented. Despite this, the new diagnosis of a sacral wound, identified on 03/31/25, was not entered into the EMR by the MDS Coordinator or other responsible staff. Interviews revealed that the MDS Coordinator was aware of the sacral wound but had not updated the EMR profile to reflect this diagnosis. The Administrator confirmed that there was no designated backup for adding diagnoses when the MDS Coordinator was absent, and acknowledged the importance of having accurate diagnoses in the EMR to reflect the resident's condition. Additionally, the facility did not have a written medical records policy available for review.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent elopement incidents involving two residents. Both residents left the facility without staff awareness, with the elopement occurring around 12:55 AM and not being discovered until after 6:00 AM during the next shift change. The staff were unaware of the residents' absence for several hours, indicating a lack of adequate supervision and monitoring. One of the residents, a female with a history of alcohol dependence, cognitive communication deficit, and other health issues, was able to remove her Wanderguard and leave the facility. Her care plan did not address elopement risks or the use of a Wanderguard, and her elopement risk assessment did not identify her as at risk. The other resident, a male with intact cognition, also left the facility without being noticed. Both residents were known to be in a relationship and were often seen together, which may have contributed to their ability to leave unnoticed. Interviews with facility staff, including the Administrator and DON, revealed that the residents were considered independent and not at risk for elopement prior to the incident. The staff's familiarity with the residents' routines and preferences may have led to a lack of vigilance in monitoring their whereabouts. The facility's failure to promptly identify and respond to the residents' absence placed them at risk for harm and serious injury.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Specifically, food items in the refrigerator, freezer, and pantry were not labeled, dated, or sealed, which is a violation of the facility's food storage policy. For instance, 16 cups of various juices and a bowl of barbeque shredded chicken in the refrigerator were not labeled or dated. In the dry storage room, a bag of dry cereal was found in a plastic storage bag that was not sealed. In the freezer, a 10-pound box of breaded chicken breast and a box of breaded yellow squash were not sealed, and a freezer-burned slab of pork ribs was found in a plastic bag that was neither sealed, labeled, nor dated. Additionally, the facility did not maintain cleanliness in the food preparation area, as evidenced by a trash can full of trash without a lid, which contradicts the facility's sanitization policy. Lighter fluid was also improperly stored in the dry food storage area, posing a risk of contamination. Interviews with the Nutrition Aide and Dietary Manager revealed that staff were trained on proper labeling, dating, and sealing of food items, but there were issues with compliance. The Dietary Manager acknowledged the risk of cross-contamination due to these oversights, and the Administrator recognized the potential for contamination due to improper food storage and trash management.
Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not address the resident's elopement risk or the use of a wanderguard, despite the resident having a history of elopement and wearing a wanderguard. This oversight was identified during a review of the resident's care plan and elopement risk assessment, which did not reflect the resident's current needs and risks. Interviews with facility staff revealed a lack of clarity and responsibility regarding the updating of care plans. The RN and DON both acknowledged that the care plan should have been updated to reflect the resident's elopement risk and wanderguard usage. The Administrator expressed that the care plan was not a major concern, focusing instead on the resident's placement. The facility's policy requires that care plans be updated to incorporate identified problem areas and risk factors, but this was not adhered to in this case, potentially placing the resident at risk of elopement and inadequate care.
Failure to Document Elopement Attempt
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who attempted to elope. The incident involved a resident with multiple diagnoses, including alcohol dependence, psychoactive substance abuse, cognitive communication deficit, generalized anxiety disorder, diabetes, depression, and essential hypertension. On the date of the incident, the resident removed her Wanderguard and attempted to leave the facility, expressing a desire to go home. Despite the resident's actions and the initiation of 1:1 monitoring due to the elopement risk, the facility did not complete an incident report as required by their policy. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of clarity and responsibility regarding the completion of the incident report. The DON, who was new to the position at the time, was unaware of the incident and could not locate a report. The Administrator believed that an incident report was unnecessary since the resident did not actually leave the premises. However, the facility's policy clearly states that an incident report should be completed immediately upon awareness of any accident or incident, which was not adhered to in this case.
Failure to Maintain Safe Sharps Disposal Practices
Penalty
Summary
The facility failed to maintain a safe environment by not ensuring that contaminated sharps disposal bins attached to nurse medication carts and a treatment cart were kept below the full line. Observations revealed that the sharps bins on the 100 and 400 Hall Nurse Medication Carts, as well as the facility's only treatment cart, were filled past the full line, posing a risk of exposure to contaminated sharps and potential bloodborne pathogens. LVN F, responsible for the treatment cart, acknowledged the hazard posed by overfilled sharps bins, as did LVN G and LVN H, who were responsible for the 400 and 100 Hall Nurse Medication Carts, respectively. Interviews with the ADON and the Executive Director confirmed that nursing staff were expected to change the sharps bins when they became full, as overfilled bins could not close properly and posed a risk of harm to residents and staff. The facility's policy on sharps disposal, revised in January 2012, required designated individuals to replace containers when they were 75% to 80% full. However, the facility's policy on accidents and hazards did not reflect the facility's role in preventing such hazards, indicating a gap in policy implementation and oversight.
Failure to Notify Physician of Missed Dialysis Appointments
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a change in the resident's status. This deficiency was observed in two residents who missed their scheduled dialysis appointments due to transportation issues. The facility did not notify the attending physician or document the missed appointments, which is a requirement when there is a change in a resident's condition. Resident #1, a female with end-stage renal disease and other medical conditions, missed her dialysis appointment because the contracted transport service was unavailable. Despite attempts to reschedule, no alternative appointments were available. The facility's RN D did not notify the resident's physician or document the missed appointment, which could have led to serious health risks such as fluid overload. Interviews revealed that the facility's receptionist failed to communicate the transport cancellation, and the facility van was not available in time to transport the resident. Similarly, Resident #2, who also has end-stage renal disease, missed her dialysis appointment due to the same transportation issue. The facility did not notify her physician or document the missed appointment. Interviews with staff indicated a breakdown in communication and failure to arrange alternative transportation. The facility's policy requires notifying the physician of any changes in condition, but this was not followed, potentially putting residents at risk.
Failure to Provide Dialysis Transportation
Penalty
Summary
The facility failed to ensure that two residents who required dialysis received the necessary transportation to their appointments. On a specific date, the contracted transport service canceled the scheduled transportation for these residents, and the facility did not make alternate arrangements. This oversight resulted in both residents missing their dialysis appointments, which could potentially lead to health complications such as fluid overload. The report details that the facility's receptionist was informed of the cancellation by the transport company but did not communicate this to other staff or arrange for alternative transportation. The facility's van was unavailable because the driver had taken the keys home, and by the time the keys were retrieved, the dialysis appointments had already passed. The facility's staff, including the BOM and RN, were aware of the missed appointments but did not notify the residents' physician or family members as required by the facility's policy. The residents involved had significant medical histories, including end-stage renal disease requiring regular dialysis. Despite the missed appointments, both residents were reported to be stable, and no immediate adverse effects were noted. However, the failure to provide transportation and the lack of communication among staff highlighted deficiencies in the facility's processes for ensuring continuity of care for residents requiring dialysis.
Failure to Maintain Cleanliness and Functional Door Handles
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents. Specifically, the restroom in the room shared by two residents was found to be unclean, with a dried black substance resembling fecal matter on the floor and toilet seat. One of the residents in this room was severely cognitively impaired and always incontinent of bowel and bladder, making the cleanliness of the restroom particularly critical. The other resident was not present during the observation. The Director of Nursing (DON) acknowledged that the presence of feces on the ground posed a risk of contact or stepping on it, and the Administrator confirmed that housekeeping was responsible for daily cleaning, with CNAs also expected to disinfect as needed. However, the issue was not addressed in a timely manner, leading to an unsanitary environment for the residents involved. Additionally, the facility failed to ensure that two other residents had a functional door handle in their room. The lever on the inside of their room door was missing, making it difficult to open the door from the inside. One of the residents, who had intact cognition, reported that the lever had been missing for a while but did not express concern as they kept the door open and used a privacy curtain. The other resident had moderate cognitive impairment and was not interviewable. The Administrator acknowledged the risk of not being able to open the door in an emergency and stated that the door handle was fixed immediately upon notification, but could not confirm how long it had been missing.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADL) care, specifically timely incontinent care, for two residents. Resident #1, a female with moderate cognitive impairment and multiple health conditions, was observed in a room with a strong smell of urine. She reported not having been changed since 4 AM, despite pressing the call light at 9:40 AM. A CNA turned off the call light without providing care, and Resident #1 did not receive incontinent care until 11:45 AM. Her care plan required incontinent care every 2 hours, highlighting a failure to meet her needs. Resident #2, who has no cognitive impairment but suffers from various health issues including muscle weakness and paralysis of the right hand, also experienced delays in receiving incontinent care. She reported not having her brief changed since 6:00 AM and described a pattern of aides turning off her call light without providing care. She expressed feelings of neglect and reported developing a rash due to the lack of timely care. Her care plan also required assistance with ADL care, including incontinent care every 2 hours, which was not adhered to. Interviews with staff revealed issues with staffing, particularly in the 200-hall, where both residents reside. CNA-B confirmed the hall was understaffed and admitted to turning off Resident #1's call light without providing care due to being pulled to assist in another hall. CNA-C stated she would not provide care to residents who were rude or abusive, opting to switch assignments with other CNAs. The Administrator acknowledged the expectation for call light responses within 10 minutes and emphasized the responsibility of all staff to respond to call lights, but admitted to staffing challenges and the need for communication with residents when care could not be immediately provided.
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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