Thrive Rehabilitation Of Pearland
Inspection history, citations, penalties and survey trends for this long-term care facility in Pearland, Texas.
- Location
- 3406 Business Center Drive, Pearland, Texas 77584
- CMS Provider Number
- 676436
- Inspections on file
- 33
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 13 (5 serious)
Citation history
Health deficiencies cited at Thrive Rehabilitation Of Pearland during CMS and state inspections, most recent first.
A resident admitted for hospice respite care with intact skin but multiple risk factors for pressure injury did not receive timely Braden risk assessment or an opened, active care plan for pressure ulcer prevention at admission. A hospice RN ordered use of a comfort chair several times daily, which staff misinterpreted, leading to the resident being placed in a chair and left there through a full night shift without documented repositioning. The night CNA interpreted the resident’s sleepiness and leaning back as refusal to get into bed, did not review the chart, did not notify licensed staff, and did not report an open sore she observed on the sacrum. By the next morning, the resident was still in the chair in the same clothes, and an open dark purple sacral wound was found and later staged as a stage 2 pressure ulcer. Facility policy requiring admission skin assessment, Braden scoring on admission, and immediate preventive interventions and care planning for at-risk residents was not followed until after the ulcer developed.
A resident with multiple serious health conditions experienced a critical low blood glucose level and a change in condition, including confusion and cold extremities. Nursing staff were unable to obtain vital signs and did not promptly notify the physician or escalate to the Medical Director as required by policy. The critical lab result was not effectively communicated, and the resident was later found unresponsive and pronounced deceased by EMS.
A resident with multiple complex medical conditions was discharged after being found non-compliant with the facility's non-smoking policy. The resident was informed she had to leave the same day, with only a brief period to decide between transferring to another facility or discharging home. Required written notice and notification to the ombudsman were not documented, and staff interviews confirmed the expedited discharge process.
A resident with dysphagia and other medical conditions experienced a choking incident that led to a change in diet from soft and bite-sized to pureed, as ordered by the physician. However, the care plan was not updated by the interdisciplinary team to reflect this new dietary order, despite facility policy requiring such updates after a change in condition. Staff interviews confirmed the care plan remained outdated following the incident.
A resident with heart failure, seizures, and chronic kidney disease was given 3L O2 via nasal cannula without a physician's order, despite facility policy requiring such an order and documentation. Staff confirmed the absence of an order and were unsure why it was missing, even though the resident's care plan and prior hospital records indicated continuous oxygen use.
A resident who required hemodialysis and attended treatments three times weekly did not have a physician's order for dialysis in the medical record. Staff confirmed that without this order, those unfamiliar with the resident might not be aware of the dialysis schedule or needs. The resident's care plan noted dialysis dependence but did not specify ongoing treatment, and facility policy requires such orders to be in place.
A nurse failed to follow infection prevention protocols while providing care to a resident with a suprapubic catheter and midline IV on Enhanced Barrier Precautions. The nurse did not wear a gown, did not change gloves between dirty and clean tasks, and cleaned the catheter incorrectly, all contrary to facility policy and physician orders. These actions were confirmed through observation and staff interviews.
A resident with multiple medical conditions and recent hip surgery did not have a care plan that included required adaptive devices or specified two-person assist for transfers, despite hospital and therapy recommendations. Staff were inconsistently informed about the resident's needs, and documentation was lacking. This led to an inappropriate single-person transfer without proper equipment, resulting in a hip dislocation.
A resident with a recent joint replacement and multiple health conditions was transferred by a CNA without the required two-person assist and without a gait belt, contrary to the care plan and facility policy. This improper transfer resulted in a hip dislocation, and staff interviews confirmed that the resident always required two-person assistance for transfers.
A resident with multiple complex medical conditions was transferred to a hospital and subsequently not allowed to return to the facility. The facility did not provide or document written notice of its bed-hold and readmission policies, nor did it issue a discharge order or summary. Staff cited behavioral concerns as the reason for non-readmission, but there was no supporting documentation. The required discharge notice, preparation, and orientation were not given to the resident or her family.
Staff failed to perform and document physician-ordered pain monitoring for a resident with a recent hip fracture and multiple comorbidities. Pain assessments were not completed or recorded for two consecutive days, and video evidence showed a CNA transferring the resident without proper assistance or pain assessment, in violation of facility policy and professional standards.
A resident with diabetes and other comorbidities experienced a critically low blood sugar episode that was not properly monitored or followed up by nursing staff. After initial EMS involvement and glucagon administration, the resident's blood sugar was not rechecked for over 13 hours, and the physician was not notified. The resident was later found unresponsive with severe hypoglycemia and required emergency hospital care, highlighting failures in monitoring, documentation, and adherence to hypoglycemia protocols.
A resident with diabetes and multiple comorbidities experienced two episodes of severe hypoglycemia and altered mental status. Nursing staff failed to notify the physician after both events, did not perform ongoing monitoring or proper documentation, and did not use required communication tools, resulting in delayed medical intervention and eventual hospitalization.
The facility failed to complete baseline care plans within 48 hours for three residents, including a male with hemiplegia, a female post-surgery, and a female with spinal stenosis. This delay in care planning could impact the continuity of care and communication among staff, as the facility's policy requires timely development of care plans to address initial needs and risks.
The facility failed to store and label food items according to professional standards, with unlabeled bacon and thickening agents, and unsealed sausage patties found during a survey. The Dietary Director acknowledged the risk of foodborne illnesses due to these lapses.
The facility failed to clean the lint filter in Dryer #2 for 19 hours, leading to a significant lint buildup, as observed by the Maintenance Director. The Lint Trap Cleaning Log showed no entries for the entire day, with the last cleaning recorded the previous morning. The Maintenance Director admitted staff oversight, acknowledging the fire hazard risk to residents.
A medication cart in the 500/600 hall was found unlocked and unsupervised, with medications accessible, while the nurse was in a resident's room. The facility's policy requires carts to be locked at all times, a standard reiterated by both the RN and DON during interviews.
A long-term care facility failed to maintain an effective infection prevention and control program, leading to deficiencies such as improper isolation for a resident with E. Coli, inadequate PPE use by staff, lack of a water management program, and improper handling of dirty laundry. These lapses could expose residents to infectious diseases.
A facility failed to provide adequate pharmaceutical services, resulting in missed doses of Morphine for a resident with chronic pain. The medication was not available on time, and there was confusion about obtaining it from the emergency kit. Additionally, the medication cart contained expired and discontinued medications, posing a risk of incorrect administration. The DON and Administrator acknowledged lapses in following medication administration policies.
The facility employed Med Aide G, who had a conviction for aggravated assault, a barrable offense under Texas law. Despite a background check revealing this conviction, the facility allowed her to work for 11 months due to a misunderstanding of barring conditions by the Administrator. Upon realizing the error, the facility decided to terminate her employment.
A facility failed to ensure accurate PASRR screening for a resident with mental health disorders, including bipolar disorder and major depressive disorder. The resident was not identified as having a mental disorder on the PASRR Level 1 Screening, despite active diagnoses and use of antidepressant medication. The MDS Coordinator did not review the PASRR and relied on previous facility information, risking the resident not receiving necessary specialized services.
A resident with severe cognitive impairment was administered Bactrim after the prescribed period ended, without a new order. The LVN failed to verify the physician's orders before administration, leading to unnecessary antibiotic use. The facility's policy on medication administration was not followed, risking antibiotic resistance.
The facility failed to properly dispose of garbage, as one dumpster lid was left open, potentially exposing residents to germs and diseases. The Maintenance Director suggested the wind might have blown it open, while the Dietary Director was unaware of his responsibility for both dumpsters. The facility's policy requires daily inspections to ensure lids are closed, which was not followed.
Two residents with indwelling catheters were observed without privacy covers on their catheter bags, compromising their dignity. Despite physician orders and care plans, staff failed to ensure privacy covers were in place due to oversight and lack of separate covers for hospital bags. Interviews revealed a lack of awareness and availability of privacy covers, and a family member confirmed the absence during visits.
A resident with an indwelling urinary catheter was found with the catheter bag and tubing on the floor, leaking, which could increase the risk of infection. Despite staff training on catheter care, the bag was not properly positioned, as confirmed by interviews with a Med Aide, an LVN, and the DON. The resident's care plan required the catheter to be in a privacy bag and secured with a leg strap, but these measures were not followed.
Failure to Prevent Pressure Ulcer After Resident Left in Chair Overnight Without Adequate Skin Monitoring
Penalty
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.
Failure to Promptly Report Critical Lab Result and Change in Condition
Penalty
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.
Failure to Provide Required Discharge Notice and Notification
Penalty
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.
Failure to Update Care Plan After Change in Resident's Condition
Penalty
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.
Oxygen Administered Without Physician Order
Penalty
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.
Failure to Obtain Physician Order for Hemodialysis
Penalty
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.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
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.
Failure to Update and Implement Care Plan for Post-Surgical Resident Results in Injury
Penalty
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.
Failure to Provide Adequate Supervision During Resident Transfer
Penalty
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.
Failure to Provide and Document Bed-Hold Policy and Discharge Notice
Penalty
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.
Failure to Perform and Document Physician-Ordered Pain Monitoring
Penalty
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.
Failure to Monitor and Respond to Hypoglycemia in Diabetic Resident
Penalty
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.
Failure to Notify Physician After Resident's Significant Change in Condition
Penalty
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.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
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.
Food Storage and Labeling Deficiencies
Penalty
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.
Failure to Maintain Lint Filter Safety in Laundry Room
Penalty
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.
Medication Cart Security Lapse
Penalty
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.
Infection Control Deficiencies in LTC Facility
Penalty
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.
Failure in Pharmaceutical Services and Medication Management
Penalty
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.
Failure to Adhere to Employment Screening Regulations
Penalty
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.
Inaccurate PASRR Screening for Resident with Mental Disorders
Penalty
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.
Unnecessary Antibiotic Administration Due to Order Verification Failure
Penalty
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.
Improper Garbage Disposal
Penalty
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.
Failure to Provide Privacy Covers for Catheter Bags
Penalty
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.
Inadequate Catheter Care Leads to Infection Risk
Penalty
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.
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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