Thrive Rehabilitation Of Pearland

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure its medication error rate remained below 5 percent and was cited for a 16.0% medication error rate based on 4 errors out of 25 opportunities involving 2 residents. The errors were identified during observation, interview, and record review and involved incorrect medication verification, dispensing, and administration by medication staff. For one resident with end stage renal disease, chronic kidney disease, shortness of breath, and a BIMS score of 8, MA J dispensed two 80 mg Furosemide tablets instead of one 80 mg tablet until surveyor intervention. MA J also did not administer the resident’s Calcium-Vitamin D 600-200 mg supplement during the medication pass, and the DON later reviewed the eMAR and confirmed the dose was not given because it was documented as unavailable. For another resident with dysphagia following cerebral infarction, hypertension, cerebral infarction, and an aneurysm of the ascending aorta without rupture, LVN A administered approximately 16 ml of Amantadine HCL instead of the ordered 20 ml via PEG tube. LVN A also administered Doxazosin Mesylate incorrectly by giving an additional 4 mg tablet on top of the ordered 8 mg dose via PEG tube. Interviews with the staff and DON confirmed the orders were not read or verified correctly before administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation of the kitchen, insulated dome covers, bases, and plates were stored on a 5-tier shelf next to the steam table and a floor drain, and crumb-like beige particles were noted on the insulated bases and on the floor around the shelf. The shelf itself was observed to have discoloration and particles adhered to its surface, and there was a cup of white solution on the third shelf that was covered but not dated or labeled. In the dry pantry, surveyors observed 3 packaged stacks of corn tortillas with an expiration date of 12/24/2024, including one stack knotted closed without a dated label. A partially wrapped package of pasta was open to air without a label or date. A large clear bin of a white substance on the lowest shelf had a handwritten date of 1/2/2026 and a shelf life of 1/6/2026, along with a barcode label showing a delivery date of 6/2/2025. In the walk-in refrigerator, surveyors found a container of peeled cooked eggs with an expiration date of 3/26/2026, a gallon-size Ziploc bag with solid red contents that was not labeled or dated, 3 clear bins of yellow solution that were not labeled or dated, and 2 stacked buckets of Rich's chocolate with an expiration date of 12/28/2025 that had furry black spots measuring 1-2 cm on the sides and lids. In the walk-in freezer, surveyors observed a package of unknown white cubed contents wrapped in clear wrapping that was not labeled or dated and was open to air, a gallon-size Ziploc bag of unknown red contents that was not labeled or dated, and a bag of mozzarella breadsticks that was open to air without a label or date. Interviews with the Head [NAME], cooks, the tray aide, the interim administrator, and the dietician showed that the dietary manager had left the facility, staff stated that whoever opens food is responsible for labeling and dating it, and multiple staff were not aware of the expired, unlabeled, or undated food items. The facility policy titled Food Storage Principles required proper labeling, dating, discarding expired foods, and keeping food storage areas clean and free of spills and leaks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents with documented mental illness diagnoses received accurate PASRR Level I screening and PASRR Level II evaluation. Resident #17 was admitted with diagnoses including epilepsy, schizophrenia, hemiplegia and hemiparesis following an intracerebral hemorrhage, and cognitive communication deficit. Her record showed a BIMS score of 12, active diagnoses of seizure disorder/epilepsy and schizophrenia, a care plan addressing schizophrenia with hallucinations, and orders for Olanzapine and Keppra. Her PASRR Level I dated at admission indicated “No” for mental illness and “No” for developmental disability, and no updated PASRR was found. Resident #4 was admitted with diagnoses including acute pyelonephritis, psychotic disorder with delusions due to a physiological disorder, and bipolar disorder. Her record showed a BIMS score of 4, active diagnoses of bipolar disorder and psychotic disorder, a care plan focused on bipolar disorder, and a medication order for Risperdal. Her PASRR dated at admission and a later PASRR both indicated “No” for mental illness and “No” for developmental disability, and no additional or updated PASRR was located. During interview, Social Services stated that residents with diagnoses such as mental disorders would require a PASRR Level II screening and an updated Level I PASRR reflecting the mental illness. Social Services reviewed the records for both residents and acknowledged their diagnoses of schizophrenia and bipolar disorder. The DON stated she was not aware of the incorrect PASRRs for either resident, and the MDS nurse stated the PASRR should have been changed to reflect the most recent information and that an inaccurate PASRR could affect whether residents received needed services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate treatment and services for a resident with a gastrostomy tube when LVN A administered enteral medications without following the documented tube-placement verification procedure and without using the ordered medication preparation and flush process. The resident was a male admitted with dysphagia following cerebral infarction, hypertension, cerebral infarction, and an aneurysm of the ascending aorta without rupture. His MDS assessment showed a BIMS score of 99, indicating he was unable to complete the interview. During observed medication administration, LVN A prepared multiple medications for g-tube administration, including Amantadine HCL, Amlodipine, Amoxicillin-Pot Clavulanate, Vitamin C, Donepezil HCL, Doxazosin Mesylate, Doxazosin, and Metoclopramide. LVN A poured approximately 16 ml of Amantadine HCL into a medicine cup and crushed the remaining tablets separately, then added 5 ml of water to each medication cup. She inserted the plunger into the end of the g-tube and poured 30 ml of water by gravity, but did not verify tube placement before starting medication administration. She stated she did not aspirate stomach contents and that she only looked at the water going down the tube. LVN A administered each crushed medication one by one with 10 ml of water in between and 30 ml of water after the last medication, but 5 of the 8 medicine cups still contained residual crushed medication. She stated she should have used a spoon to stir the medications so they would dissolve completely and could not identify which medications had residuals. After gathering more water and a spoon, she dissolved the remaining residual medication and administered those doses. She also stated she did not administer the full 20 ml of Amantadine HCL as ordered. The facility policy required verification of tube placement by air insufflation and listening for gurgling or by aspirating stomach contents, dissolving crushed tablets in 30 ml of warm water or other appropriate liquid, and flushing the tube with 5 ml of water after each dose.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles and included expiration dates when applicable. During review of the 400-hall medication cart, Resident #31 had one opened box of Ipratropium Bromide 0.02 mg/Albuterol sulfate 2.5 ml/3 ml inhalation solution with an opened foil packet containing 3 vials and a written date of 1/16/2026. The report stated the medication was not labeled with the expiration date and was not discarded after 14 days according to facility policy. During review of the 600-hall medication cart, Resident #6 had one opened box of Ipratropium 0.02%/2.5 ml inhalation solution with an opened foil packet containing 2 vials and a written date of 3/18/2026, one opened box of Levalbuterol 1.25 mg/3 ml inhalation solution with an opened foil packet containing 2 vials and a written date of 3/14/2026, and one opened box of Ipratropium Bromide 0.5 mg/Albuterol sulfate 2.5 mg/3 ml inhalation solution with an undated opened foil packet containing 4 vials. The report stated these inhalation solutions were not labeled with the expiration date and were not discarded after 14 days according to facility policy. Resident #31 was admitted with diagnoses including unspecified dementia, unspecified respiratory disorder, and essential hypertension. Resident #6 was admitted with diagnoses including chronic respiratory failure and pleural effusion. Staff interviews showed the LVNs were not sure of the facility policy for expiration of opened foil packet inhalation solutions, and one LVN was not aware that one medication in the cart was undated. The DON, ADON, and DOD stated that opened foil packets of inhalation solutions expire 14 days after opening and should be labeled with the opened date and expiration date, and the facility policy stated inhaled items must have the date open on the inhaler or HHN foil packet and that HHN foil packets expire 14 days after opening.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide necessary pressure ulcer prevention and care to a cognitively impaired, bed-confined hospice respite resident who was admitted with intact skin but identified as at risk for pressure ulcer development. On admission, the resident’s assessment documented dementia, severe cognitive impairment (BIMS score 0), heart failure, low body mass index, bed confinement, and total dependence for transfers and bed mobility. The admission assessment noted intact skin and no skin issues, but the facility did not have an admission Braden skin risk assessment documented as required by policy, and no admission skin assessment was found in the record. The baseline care plan focused on respite and comfort related to hospice status and did not initially include a pressure ulcer prevention plan, and the comprehensive care plan remained closed from view until several days after admission. On the second day of the stay, a hospice RN communicated that the resident should be placed in a chair with arms several times daily, but this order was interpreted and implemented in a way that did not ensure appropriate repositioning and monitoring. CNA A placed the resident in a comfort chair in the afternoon and reported to CNA B at shift change that the resident remained in the chair. CNA B, working the night shift, encountered the resident sleepy in the chair, attempted to interact with her, and, when the resident leaned back and did not verbalize, interpreted this as refusal to get out of the chair. CNA B left the resident in the chair throughout the night, later stating she probably left her there because the resident was comfortable and it was not a dangerous situation. CNA B did not review the resident’s medical history or admission paperwork, did not notify the nurse, ADON, DON, or oncoming aide that the resident had remained in the chair or that she observed an open sore on the resident’s bottom, and did not document any refusal or skin concern. By the following morning, when CNA A returned, the resident was still in the chair wearing the same clothes as the previous day, and during peri care CNA A observed an open dark purple wound on the sacrum. The ADON was notified and later identified the area as a stage 2 pressure ulcer, documenting an open abrasion with a crater and dry tissue on the lower coccyx. Subsequent skin observation documented worsening with surrounding red/purple discoloration and maceration of the buttock. The facility’s own skin breakdown prevention and management policy required an initial skin and risk assessment upon admission, Braden assessments on admission and weekly for four weeks, and initiation of preventive measures and an admission care plan for residents at risk, but the Braden assessment was not completed until several days after admission and the care plan for wound prevention and treatment was not opened and updated until after the ulcer was identified. The ADON acknowledged that the order to use the comfort chair could have been misinterpreted by staff, that the care plan was not opened at admission, and that not checking on the resident did not help, while the night RN could not clearly confirm the resident’s position during night rounds. These actions and inactions resulted in the resident, who was at moderate risk for pressure ulcers, remaining in a chair for an extended period without documented repositioning or appropriate preventive interventions, leading to the development and worsening of a pressure ulcer. The facility’s policy also required that residents at risk for pressure ulcers receive individualized care plans including pressure-relieving devices, turning and positioning, incontinence management, and protection from moisture, as well as timely investigation and documentation of any skin breakdown. In this case, the resident’s prior history of a sacral pressure ulcer during an earlier respite stay was known to the hospice RN and discussed with the ADON, but this history was not reflected in the admission assessments or used to trigger early preventive interventions such as support surfaces. The Braden assessment completed later showed a score of 13, indicating moderate risk, with very limited sensory perception, bedfast status, very limited mobility, and friction/shear risk, yet these risk factors were not systematically addressed from admission. The combination of delayed risk assessment, failure to open and implement a preventive care plan at admission, misinterpretation of the chair order, lack of effective night-time monitoring and repositioning, and failure to communicate and act on observed skin changes directly preceded the identification of a new stage 2 pressure ulcer on the resident’s sacrum.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to promptly report a critical laboratory result to the ordering practitioner for a resident with multiple complex medical conditions, including cancer, end-stage renal disease requiring hemodialysis, heart failure, and acute kidney failure. The resident had a critical low blood glucose value of 42, which was identified after blood was drawn at dialysis. The laboratory notified the facility of this result, but the nurse on duty was unable to reach the physician and only sent a text message, receiving no response. No further escalation was attempted, and the Medical Director was not contacted as required by facility policy. The resident had exhibited a change in condition, including confusion and cold extremities, on the evening prior to being found unresponsive. Staff had difficulty obtaining vital signs, particularly oxygen saturation, and these issues were reported among the care team. Despite these signs and the critical lab value, there was no documented evidence that the physician was promptly notified or that additional monitoring or interventions were initiated in response to the abnormal findings. The resident was later found unresponsive and was pronounced deceased by EMS. Interviews and record reviews revealed that staff were aware of the abnormal findings and the facility's policies required immediate physician notification for critical lab results and changes in condition. However, the nurse did not follow the escalation protocol when the physician could not be reached, and there was a lack of timely and effective communication among the care team regarding the resident's deteriorating status. The failure to report the critical lab result and adequately respond to the change in condition constituted the identified deficiency.

Removal Plan

• RN A initiated CPR immediately after being notified by CNA B that no vital signs could be obtained. 911 was called and EMS assumed care upon arrival. When EMS determined the presence of post-mortem changes and pronounced death, the resident was respectfully prepared, and family/representatives were notified according to facility protocol.
• RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition. During this education, the DON/designee reviewed the Handoff Communication policy to clarify expectations of correctly rounding residents at end and beginning of the shift.
• CNA B and LVN B were provided with 1:1 education by DON/designee on how to obtain vital signs according to vital signs policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with both employees to clarify when immediate notification with licensed nurse or RN supervisor and/or physician notification is required for abnormal vital signs.
• LVN B received 1:1 education from the DON/designee on the proper steps for reporting critical lab results and abnormal vital signs in accordance with the facility's Change of Condition policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with LVN B to clarify when immediate physician notification is required for critical labs and abnormal vital signs. The training education of LVN B reinforced the requirement to contact the Medical Director when the attending physician or NP is not available, ensuring timely escalation and resident safety.
• Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
• Inservice training was provided by DON/designee with all licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.
• A root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events.
• The NHA will oversee corrective actions and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action.
• Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.
• All residents were identified to be at risk for the identified deficient practice. A random audit of all in-house patients was completed by DON/designee and found a total of 8 residents have abnormal vital signs that needed to be reported to physicians. A random audit of all vital signs taken for all residents completed by DON or designee showed that there was a total of 8 residents potentially affected by the deficient practice. The assigned licensed nurse completed a review of the abnormal vital signs and was reported to the attending physician. A random audit of all vital signs taken for NOC shift when incident happened was completed by DON or designee using the exception report from EMR and showed that there was a total of 8 residents meeting criteria. The following reviews and interventions were conducted by the 8 residents: BP monitoring parameters for 1 resident that is not on antihypertensive medication were added after the physician was notified; BP monitoring parameters for 1 resident that is below 100 SBP after the physician was notified; PR parameter for 1 resident that is not on any ACE, ARBs, Calcium or beta blocker was added after physician notification; 2 resident triggered as abnormal but after review is within normal limits of resident range of BP; 3 residents had over 100 PR but have medications administered.
• Training in change of condition, monitoring and reporting will be included for new hires and will be reviewed yearly by DON and DSD during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for licensed nurses and CNAs.
• The ADON/designee will conduct a random audit of residents with change of condition to determine that physicians were notified following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• The ADON/designee will conduct a random audit of residents with change of condition to determine that monitoring occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• A random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock change of condition drill to test responses of nurses on what conditions including abnormal vital signs will be reported to physicians. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.
• RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition.
• CNA B and LVN B were provided 1:1 education by DON/designee on how to obtain vital signs.
• LVN B was provided 1:1 education by DON/designee on reporting critical lab and reporting abnormal vital signs and on contacting Medical Director in case attending physician is not available.
• Inservice training was provided by DON/designee with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed.
• Inservice training was provided by DON/designee with all LNs. Staff will not be allowed to provide direct care until training has been completed. Education included: completing change of condition evaluation for residents, notifying physicians for any change of conditions, notifying the party responsible for change of conditions, notifying Medical Director in case of attending physician not answering calls, reporting critical and abnormal lab results to physician or covering physician, reporting abnormal vital signs to physicians or covering physicians, performing walking rounds at beginning and end of shift where doorway check only are not permitted unless preferred by the patient.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide required notice as soon as practicable before the transfer or discharge of a resident. The resident, a female with a history of cerebral infarction, muscle weakness, lack of coordination, type 2 diabetes with hyperglycemia, morbid obesity, and functional quadriplegia, was admitted to the facility and later found to be non-compliant with the facility's non-smoking policy. Documentation showed that the resident was informed on the same day that she had to transfer or discharge, without evidence of advance written notice or notification to the ombudsman as required. Progress notes and interviews revealed that the resident was found with a vape and other smoking materials, and was told by the social worker that she could either transfer to another facility that allowed smoking or be discharged home. The resident was given a very short timeframe—reportedly as little as 30 minutes—to make a decision about her discharge destination. The facility's staff, including the social worker and admissions coordinator, confirmed that the resident was told she had to leave that day due to violation of the non-smoking policy, and arrangements were made for her to go to a hotel with home health services set up. There was no documentation in the clinical record of a formal discharge notice or notification to the ombudsman. The facility's own transfer and discharge policy requires sufficient preparation and orientation to ensure a safe and orderly transfer or discharge, but the records and interviews indicate that the resident was not given adequate notice or options, and the process was expedited due to the policy violation. The administrator and staff interviews further confirmed that the discharge was prompted by the resident's non-compliance with the non-smoking policy and that the required notifications and documentation were not completed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the comprehensive care plan for a resident with a history of dysphagia, chronic kidney disease, muscle weakness, type 2 diabetes mellitus, and cognitive communication deficit was reviewed and revised by the interdisciplinary team following a significant change in condition. After the resident experienced a choking incident during a meal, which resulted in emergency intervention and hospitalization, the physician ordered a change in the resident's diet from Level 6 soft and bite-sized to Level 4 pureed. Despite this change, the resident's care plan was not updated to reflect the new dietary order. Record review showed that the care plan continued to list the previous diet and did not incorporate the updated pureed diet or address the recent choking event. Interviews with staff confirmed that the care plan had not been revised as required, and the DON acknowledged that nursing staff were responsible for updating the care plan but could not explain why it had not been done. The facility's policy requires care plans to be reviewed and revised after changes in a resident's condition, but this was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of heart failure, seizures, and chronic kidney disease was admitted to the facility and was observed receiving 3 liters of oxygen via nasal cannula. The resident's baseline care plan indicated he was to receive oxygen, and previous hospital records confirmed he was on continuous oxygen prior to admission. However, upon review of the resident's current physician orders, there was no documented order for oxygen administration. Nursing staff confirmed that the resident was receiving oxygen but acknowledged the absence of a physician's order in the chart and were unsure why it was missing. Facility policy requires a physician's order for oxygen administration, as oxygen is considered a drug. The policy also mandates documentation of oxygen use in the medical record, including the order, reason for use, and resident response. Despite these requirements, the resident was administered oxygen without a corresponding physician's order, and this was confirmed through observation, record review, and staff interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident requiring hemodialysis had a physician's order for the treatment, despite the resident attending dialysis three times a week. Documentation reviewed included the resident's face sheet, baseline care plan, hospital records, admission assessment, and dialysis communication forms, all of which confirmed the resident's dependence on and receipt of dialysis. However, there was no physician's order for hemodialysis in the resident's chart as of the date reviewed. Interviews with nursing staff and the DON confirmed that the absence of such an order could result in staff being unaware of the resident's dialysis needs, especially if they were unfamiliar with the resident. The resident's baseline care plan noted dependence on renal dialysis but did not specify that dialysis was being received. The facility's policies require that orders for dialysis and related care be obtained and followed upon admission, including shunt care and monitoring. Despite these requirements, the necessary physician's order for dialysis was missing, and staff relied on verbal reports or the resident's own disclosure to know about the dialysis schedule. This lack of formal documentation and orders was directly observed and acknowledged by staff during interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a registered nurse (RN) failed to follow established infection prevention and control protocols during the care of a male resident who was newly admitted and receiving antibiotic therapy for a urinary tract infection (UTI) and had a suprapubic catheter and a midline IV. The resident was on Enhanced Barrier Precautions (EBP) as ordered by the physician, which required the use of gloves and a gown during high-contact care activities such as incontinence care and device care. Despite these orders and facility policy, the RN did not wear a gown while providing incontinence care and failed to change gloves between removing a soiled brief and applying a clean one. The RN also did not perform hand hygiene or change gloves between different care tasks, including cleaning the resident’s suprapubic catheter. During the observed care, the RN used the same gloves and wipes for multiple steps, including cleaning the resident’s perineal area, changing briefs, and cleaning the suprapubic catheter. The catheter was cleaned in a manner inconsistent with facility policy, as the RN cleaned towards the insertion site rather than away from it, increasing the risk of contamination. The RN also replaced the resident’s bedding while still wearing the same contaminated gloves. In interviews, the RN acknowledged forgetting to wear the required PPE and to change gloves, attributing this to the absence of a PPE cart and the resident being a new admission. The RN also admitted not considering the infection control implications of her actions. Facility policies reviewed included clear instructions for EBP and indwelling catheter care, specifying the use of gowns and gloves for high-contact activities and the correct technique for cleaning catheters. The Director of Nursing (DON) confirmed that staff are expected to follow these protocols, including changing gloves between dirty and clean tasks and cleaning catheters from the insertion site outward. The observed failures to adhere to these protocols were confirmed through interviews and record reviews, demonstrating a breakdown in the facility’s infection prevention and control program for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a person-centered care plan that addressed all of a resident's physical needs, specifically neglecting to include goals or interventions related to the use of adaptive devices following joint replacement surgery. The resident, an elderly male with multiple complex diagnoses including recent hip surgery, dementia, and generalized muscle weakness, was admitted after a joint replacement and required specific precautions and assistive devices such as a hip abduction pillow and two-person assist for transfers. Despite clear hospital discharge instructions and therapy recommendations, the facility's care plan, physician orders, and electronic health records did not reflect the need for these adaptive devices or specify the required assistance for transfers. Interviews and record reviews revealed that staff were inconsistently informed about the resident's needs. Some CNAs were aware of the use of cushions and wedges, while others were not, and there was confusion about when and how to use these devices during transfers and care. The MDS Coordinator stated that care plans were not updated when residents returned from hospitalization unless there were medication changes, and the care plan for this resident was not revised to reflect the need for adaptive devices or changes in transfer assistance. The lack of clear, updated documentation and communication led to staff performing transfers without the required two-person assist or use of a gait belt, as evidenced by video footage showing a CNA transferring the resident alone and without proper equipment. As a result of these failures, the resident experienced a right hip dislocation following an inappropriate transfer. The facility's policies required safe transfer practices, use of gait belts, and immediate communication of patient needs, but these were not followed or reflected in the care plan. Staff interviews confirmed gaps in knowledge and inconsistent practices regarding the use of adaptive devices and transfer assistance, and the care plan was not updated to reflect the resident's changing needs after hospitalization and surgery.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) transferred a male resident, who had a recent joint replacement and multiple comorbidities including dementia, diabetes, and a history of fractures, without the required two-person assistance. The resident's care plan specifically indicated the need for a two-person assist for transfers due to his medical condition and risk factors. Despite this, the CNA performed a stand and pivot transfer alone, did not use a gait belt, and left a cushion between the resident's legs during the process. The transfer was captured on video, and the CNA acknowledged transferring the resident alone on multiple occasions, justifying the action by the resident's small stature. Following the transfer, the resident experienced a dislocation of his right hip arthroplasty, as confirmed by radiographic imaging. The care plan and medical records had not been updated to reflect any changes in transfer needs after the resident's return from hospitalization, and staff interviews confirmed that the resident consistently required two-person assistance for transfers. Multiple staff members, including CNAs, nurses, and the Director of Nursing (DON), stated that improper transfers could result in injury or death, and that the resident was at risk for falls as indicated in his care plan. The facility's policies required the use of proper transfer techniques, including the use of gait belts and adherence to care plans specifying the number of staff needed for transfers. The policy also outlined the responsibilities of staff to communicate changes in mobility needs and to use mechanical lift equipment as appropriate. Despite these policies, the CNA did not follow the established procedures, resulting in an incident that led to the identification of Immediate Jeopardy by surveyors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide and document sufficient preparation and orientation to a resident and her family regarding the facility's bed-hold policies during a discharge event. The resident, who had multiple complex medical diagnoses including rheumatoid arthritis, multiple sclerosis, chronic pain, and moderate cognitive impairment, was transferred to the hospital for abdominal pain and related medical interventions. There was no evidence in the medical record of a discharge order, discharge summary, or physician's handwritten progress note detailing the discharge. The resident reported that she was promised she could return to the facility if she ever went to the emergency room, but while hospitalized, she learned from a hospital counselor that the facility would not allow her to return. The facility staff communicated this decision to the resident while she was still in the hospital, citing aggressive behavior and non-compliance with treatment as reasons, but there was no documentation in the facility records to support these claims. The resident was not notified in advance that she would not be allowed to return, and her belongings remained in her room until her family member retrieved them. Interviews with facility staff, including the admission coordinator, DON, ADON, and administrator, revealed inconsistent accounts regarding the reasons for the resident's discharge and lack of documentation of the alleged behaviors. The facility's own transfer and discharge policy requires written notice of bed-hold and readmission policies, documentation of the discharge process, and communication with the resident and family, none of which were found in this case. The required discharge notice, documentation of preparation and orientation, and explanation of appeal rights were not provided to the resident or her family.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically by not performing physician-ordered daily pain monitoring. The resident, an elderly male with a complex medical history including joint replacement surgery, diabetes, hypertension, dementia, and a recent hip fracture, had a physician order for pain monitoring every shift using a verbal/nonverbal 0-10 scale. Documentation and interviews revealed that pain assessments were not completed or recorded for two consecutive days, despite the ongoing order and the facility's policy requiring pain assessment every shift. Record reviews showed that the resident's Medication Administration Record (MAR) did not include documented pain levels, and there were no progress notes, assessments, or vitals indicating pain monitoring for the specified dates. Video evidence further demonstrated that a CNA transferred the resident without a second person assist, did not use a gait belt, and did not assess or report the resident's pain using the required scale. Multiple staff interviews confirmed inconsistent understanding and execution of pain assessment protocols, with some staff unable to recall if pain assessments were completed or documented as required. The facility's pain screening and assessment policy mandates that every shift, a pain score must be documented for each resident, and that comprehensive pain assessments are to be performed for residents with a positive pain score. The policy also requires that pain intensity be included as the fifth vital sign during routine vitals. Despite these requirements, the resident's pain monitoring was not performed or documented as ordered, constituting a failure to provide care in accordance with professional standards and the facility's own policies.

Penalty

Inspection fine: $35,66518 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to provide treatment and care in accordance with professional standards of practice, the resident's care plan, and the resident's choices for a resident with multiple comorbidities, including end-stage renal disease, hypertension, and diabetes mellitus. The resident was found lethargic with a critically low blood sugar reading that did not register on the monitor, and after administration of glucagon, her blood sugar was recorded at 25 mg/dL. EMS was called, but the resident was not transported to the hospital at that time, and the physician was not notified of the change in condition. There was no documentation of ongoing monitoring or follow-up by nursing staff after this event. For approximately 13 hours following the initial hypoglycemic episode, the resident's blood sugar was not monitored, and there were no further nursing assessments or documentation regarding her condition. The resident was later found unresponsive with a blood sugar of 21 mg/dL, and EMS was called again. This time, the resident was transported to the hospital, where she was admitted with altered mental status and hypoglycemia, and subsequently required ICU care due to worsening hypotension. Interviews with staff revealed that the physician was not notified of the resident's critical condition, and there was a lack of adherence to the facility's hypoglycemia protocol, which required frequent blood sugar monitoring and physician notification for low blood glucose levels. The facility's change of condition policy, which mandates physician notification and documentation using the SBAR tool, was not followed. The failure to monitor the resident's blood sugar, notify the physician, and document the resident's status after a critical event led to a second hypoglycemic episode and the need for emergency medical intervention.

Penalty

Inspection fine: $35,66518 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when facility staff failed to notify a resident's physician following significant changes in the resident's physical and mental status. The resident, an elderly female with a history of end-stage renal disease, hypertension, diabetes mellitus, and urinary tract infection, was found lethargic with a critically low blood sugar level. Despite the severity of her condition, including an unregistered blood sugar reading and subsequent administration of glucagon, the physician was not contacted for guidance or orders. EMS was called, and the resident was stabilized on the unit, but there was no documentation of physician notification or further medical assessment at that time. The following day, the same resident experienced another severe episode, being found unresponsive with a blood sugar reading of 21. Glucagon was administered again, and EMS was called, resulting in the resident's transfer to a local hospital where she was treated for hypoglycemia and altered mental status. Nursing notes revealed a lack of ongoing monitoring, assessment, and documentation between the two events, with no SBAR communication or follow-up notes recorded. Interviews with staff confirmed that the physician was not notified during either event, and there was a failure to monitor the resident's blood sugar at appropriate intervals or document her level of consciousness and intake. The facility's policy required immediate physician notification for acute or significant changes in condition, as well as the use of SBAR tools and proper documentation. However, these procedures were not followed. Staff interviews indicated uncertainty about the policy and a lack of follow-up after the initial event. The attending physician confirmed she was not notified and emphasized that the resident's blood sugar levels were critically low and required immediate medical attention and monitoring, which did not occur.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and complete a baseline care plan within 48 hours of admission for three residents, which is a requirement to ensure continuity of care and communication among staff. Resident #18, a male with hemiplegia and hemiparesis following a cerebral infarction, was admitted without a baseline care plan completed within the required timeframe. His baseline care plan was only completed several days after admission, which could have impacted the immediate care he received. Similarly, Resident #24, a female admitted for surgical aftercare following circulatory system surgery, did not have her baseline care plan completed within 48 hours. Her care plan was also delayed, potentially affecting the staff's ability to provide appropriate care and support for her functional needs, such as assistance with transfers and mobility. Resident #126, a female with spinal stenosis and moderate cognitive impairment, also experienced a delay in the completion of her baseline care plan. The facility's policy requires that a baseline care plan be developed within 48 hours to address initial needs and risks, but this was not adhered to for these residents. Interviews with staff, including the MDS Nurse and DON, revealed a misunderstanding of the policy timeframe and a lack of recent training, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, as observed during a survey. On the specified date, a cling-wrapped bunch of bacon in the refrigerator and cans of thickening agent were found unlabeled and undated with the delivery date. Additionally, a bag of sausage patties was discovered unsealed. These lapses in food storage practices were identified during an interview and observation with the acting Dietary Manager, who acknowledged the issues and attempted to rectify them by labeling the bacon with the delivery date. The Dietary Director, who had been in the role for eight months, explained the facility's policy for storing food, which includes dating single items with the day of arrival and discarding items like thickening cans if not labeled. He admitted that the failure to follow these procedures could lead to serious health risks for residents, such as foodborne illnesses. The facility's policies, as well as the U.S. Food and Drug Administration Food Code, emphasize the importance of proper labeling and storage to prevent contamination, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe environment by not ensuring the lint filters in the laundry room were cleaned at appropriate intervals. Specifically, Dryer #2 was not cleaned for 19 hours, leading to a significant buildup of lint on, above, and around the filter. This oversight was observed during a survey on January 29, 2025, when the Maintenance Director demonstrated the condition of the lint filter in Dryer #1, which also had a thick sheet of lint. The absence of laundry staff at the time of observation further highlighted the lack of supervision and adherence to safety protocols. Interviews and record reviews revealed that the facility's policy required lint traps to be cleaned several times a day to prevent fire hazards and extend the life of the dryers. However, the Lint Trap Cleaning Log for January 2025 showed no initials for the entire day of January 29, with the last recorded cleaning on January 28 at 7 am. The Maintenance Director admitted that staff were supposed to check the lint filters twice daily but had forgotten, acknowledging the potential fire hazard this posed to residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all drugs and biologicals were secured properly and labeled and stored in accordance with currently accepted professional principles. During an observation, it was noted that the medication cart for the 500/600 hall was unlocked, with the second drawer slightly ajar. This drawer contained multiple daily medications in blister packs for residents in the 500/600 hall. The nurse responsible for the cart was in a resident's room administering medications, leaving the cart open and unsupervised. Interviews conducted with RN C and the Director of Nursing (DON) confirmed the expectation that medication carts should be locked at all times. RN C acknowledged the unlocked drawer and stated that she had been trained to lock the cart before entering a resident's room. The DON reiterated that all medication carts should be locked to prevent unauthorized access. The facility's Medication Administration and Management policy also stated that medication carts should be kept in sight or locked at all times.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, which resulted in several deficiencies. One significant issue was the failure to place a resident on appropriate contact isolation for E. Coli. Despite having a urinary tract infection with ESBL E. Coli and being on IV antibiotics, the resident did not have isolation signs, and staff were observed entering the room without wearing personal protective equipment (PPE). Interviews with staff revealed a lack of awareness and understanding of the necessary precautions, contributing to the oversight. Another deficiency involved a resident who required enhanced barrier precautions due to multiple medical conditions, including a tracheostomy and gastrostomy. A CNA was observed providing incontinence care without wearing the appropriate PPE, specifically a gown, which was required under the enhanced barrier precautions. The CNA admitted to not remembering the specific requirements for isolation and PPE, indicating a gap in training and adherence to infection control protocols. Additionally, the facility failed to implement a water management program as part of its infection control efforts. The Maintenance Director was unaware of any water-borne illness policy or program, and the Administrator only conducted Legionnaire's tests annually without a comprehensive plan. Furthermore, dirty laundry was found on the floor in the laundry room, contrary to the facility's policy, which could lead to cross-contamination. These lapses in infection control practices could expose residents to various infectious diseases, including Legionnaires' disease.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services for a resident, leading to missed doses of Morphine Sulfate Oral Tablet 30 MG, which was prescribed to manage the resident's chronic pain. The resident, who had a history of spinal stenosis and cognitive impairment, was supposed to receive the medication twice daily. However, on the first day of the prescription, the morning dose was not administered because the medication was not available, and the evening dose was not given due to unspecified reasons. Interviews revealed that the medication was ordered but not received until late at night, and there was confusion about why the medication was not obtained from the emergency kit. Additionally, the facility failed to maintain the medication cart properly, as it contained discontinued and expired medications. During an inspection, it was found that the cart had medications that were either expired or belonged to residents who had been discharged. The Director of Nursing (DON) acknowledged that medications should be checked daily by nurses and removed immediately when no longer needed, but this protocol was not followed, leading to the risk of administering expired or incorrect medications. Interviews with staff, including the DON and the Administrator, highlighted a lack of adherence to the facility's medication administration policies. The DON admitted to missing expired medications during weekly checks, and the Administrator emphasized that the responsibility for removing expired medications lay with the nurses using the cart. The facility's policies required that medications be administered according to prescriber orders and that expired medications be destroyed or returned, but these procedures were not consistently followed, contributing to the deficiencies observed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with regulations by employing an individual, Med Aide G, who had a conviction for aggravated assault, which is a barrable offense under the State of Texas, Health and Safety Code. The criminal history background check conducted at the time of hiring revealed this conviction, yet the facility allowed Med Aide G to work for approximately 11 months. This oversight occurred because the Administrator misunderstood the barring conditions, believing that aggravated assault was not a barring condition unless it was a felony. During interviews, the Administrator acknowledged that Med Aide G had not received any complaints or allegations of abuse, neglect, or misappropriation during her employment. However, upon reviewing the list of barring conditions, the Administrator and COO realized their error and confirmed that aggravated assault was indeed a barring condition. Consequently, they decided to terminate Med Aide G's employment. An audit of all criminal history background checks was conducted, revealing no other issues or concerns.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) for a resident with mental health disorders. The resident, a female with diagnoses including dementia, bipolar disorder, and major depressive disorder, was not correctly identified as having a mental disorder on her PASRR Level 1 Screening. This oversight was discovered during a review of the resident's records, which showed active diagnoses of bipolar disorder and major depressive disorder, and the use of antidepressant medication. Despite these indicators, the PASRR Level 1 screening inaccurately indicated the resident was negative for mental illness. The MDS Coordinator admitted to not reviewing the PASRR for the resident and relying on information from a previous facility. This failure to update and accurately complete the PASRR could result in the resident not receiving necessary specialized services. The facility's policy requires a Level II evaluation if a Level I screening identifies potential serious mental illness, intellectual disability, or developmental disability, which was not completed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically antibiotics, without adequate indications for use. Resident #8, a male with severe cognitive impairment and multiple health conditions, was administered Bactrim (Sulfamethoxazole/Trimethoprim) after the prescribed treatment period had ended. The physician's order indicated that the antibiotic treatment was to conclude on 12/31/24, but the medication was administered again on 01/31/24. This administration occurred despite the absence of a new order for the antibiotic, as confirmed by the physician and the Licensed Vocational Nurse (LVN) involved. The incident was observed by a surveyor, who noted that the LVN administered the antibiotic without verifying the current physician's orders. The Director of Nursing (DON) and the facility Administrator both acknowledged that discontinued medications should be removed from the medication cart to prevent accidental administration. The facility's Medication Administration and Management policy emphasizes the importance of verifying orders before medication administration, which was not adhered to in this case. This oversight could lead to unnecessary and inappropriate antibiotic use, increasing the risk of antibiotic-resistant infections among residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly dispose of garbage and refuse, as observed with one of the two waste receptacles reviewed. The left dumpster had its top right lid open when it should have been closed, potentially exposing residents to germs and diseases carried by vermin and rodents. During an observation and interview, it was noted that the cleaning staff might not have been able to reach the lid to close it. The Maintenance Director suggested that the wind might have blown the lid open, while the Dietary Director was unaware that both dumpsters were his responsibility. The facility's Garbage and Trash Policy requires that garbage and trashcans be inspected daily to ensure lids are closed, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat residents with respect and dignity by not providing privacy coverings for catheter bags, affecting two residents. Resident #1, a male with multiple medical conditions including an indwelling catheter, was observed without a privacy cover on his catheter bag, which was visible from the doorway. Despite physician orders and care plans indicating the need for a privacy cover, staff interviews revealed that the cover was not in place due to oversight during the admission process and lack of separate privacy covers for hospital catheter bags. Similarly, Resident #2, also with an indwelling catheter and severe cognitive impairment, was observed with a visible catheter bag lacking a privacy cover. The care plan for Resident #2 did not address privacy concerns related to the catheter bag. Staff interviews indicated a lack of awareness and availability of privacy covers, and a family member confirmed the absence of a privacy cover during visits. The facility's policy on catheter care emphasized the importance of privacy, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, which could lead to an increased risk of urinary tract infections. The resident, a male with multiple medical conditions including epilepsy, traumatic brain injury, and quadriplegia, was observed with his catheter bag and tubing on the floor, and the bag was leaking. This observation was made during a survey, and it was noted that the catheter bag was full with urine present in the tubing. The resident's care plan and physician orders specified that the catheter should be in a privacy bag and secured with a leg strap at all times, and that the catheter, bag, and tubing should be changed as needed to prevent leakage and infection. Interviews with facility staff, including a Med Aide, an LVN, and the DON, revealed that the staff were aware that the catheter bag should not have been on the floor, as this posed a risk of infection due to cross-contamination. The Med Aide and LVN both acknowledged that they had not been in the resident's room that day, and the DON confirmed that she was unaware of the situation until it was brought to her attention. Despite being trained on catheter care, the staff failed to ensure that the catheter bag was properly positioned, which could potentially lead to a urinary tract infection for the resident.