Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Treemont Health Care Center during CMS and state inspections, most recent first.
A resident with a PICC line, open groin wound, severe cognitive impairment, and multiple chronic conditions did not receive ordered IV antibiotics when scheduled. The MAR/TAR showed both Vancomycin and Ampicillin-Sulbactam as held, and observations found no IV tubing, bag, or pump at the bedside. Staff interviews confirmed the antibiotics were not available, the resident said he had still not received them after returning to the facility, and the DON and ADM stated nursing staff should have followed up when the medications were missing.
Central line dressing change not performed using sterile technique. A resident with a right upper chest central line was receiving IV meropenem for sepsis, but the dressing remained dated and the resident said it had not been changed since admission. An LVN changed the dressing without hand hygiene, used gloves and scissors from her pocket, placed sterile supplies on an air vent, and did not maintain sterile technique. The DON stated the dressing should be changed weekly and the site observed each shift.
Medication administration errors exceeded the allowable rate when staff omitted ordered meds, gave incorrect doses, and administered several meds at the wrong time or without required food or fluids. Errors involved residents with diagnoses including GERD, hypomagnesemia, COPD, dementia, MS, anxiety, and diabetes, and included a nurse hanging IV PPI therapy incorrectly, a med aide failing to give ordered supplements, and another med aide giving multiple meds inconsistently with the MAR and physician orders.
Surveyors found expired leftover foods stored in the kitchen and meal trays served below hot-holding temperatures, with heated bases cold to the touch. Residents reported cold, unpalatable meals and delays in service, and the dietary manager stated staff were responsible for labeling, storage, recipe adherence, and ensuring heated bases were plugged in.
A resident with intact cognition, a Foley catheter, and total dependence for personal hygiene received incomplete incontinent care when a CNA did not wear a gown, did not change gloves, and did not cleanse the scrotum and buttocks before placing a clean brief. The CNA said she avoided cleaning the buttocks because of a dressing and acknowledged the missed care could cause skin break and odors. The facility policy required cleansing the penis shaft, scrotum, legs, and back side and removing gloves with hand hygiene to prevent cross contamination.
Improper Tracheostomy Care and Suctioning: An LVN failed to use sterile technique during trach care and suctioning for a resident with a tracheostomy, did not wash hands between steps, did not clean the trach site, and did not remove the inner cannula to clean or replace it. The resident had audible moist breath sounds and was coughing up a significant amount of phlegm during the procedure, and O2 saturation was not checked. The DON confirmed sterile technique was required and that the nurse had been in-serviced on trach care.
A resident with dementia, depression, anxiety, weakness, and chronic shoulder pain did not receive ordered acetaminophen at the scheduled time. The MAR showed the 8:00 a.m. dose was still not given by 9:05 a.m., and the medication was delivered at 9:45 a.m. The resident said her pain meds were sometimes late and that she did not think she had received her meds that day. The MA said she was still giving meds on another hall, and the DON said the delay happened because the MA spent extra time taking other residents' BPs. The facility policy required meds to be given within 1 hour of the prescribed time unless otherwise specified.
Failure to Communicate Pharmacist Medication Irregularity: A resident with multiple sclerosis, dementia, fractures, and muscle weakness had an order for Baclofen 30 mg TID. The consultant pharmacist identified the regimen as requiring attention and documented that the medication should be evaluated, but the record showed no documentation that the physician or DON were informed of the irregularity. The DON stated she was unaware of the recommendation and that the former ADON had been responsible for notifying the doctor.
Medication Given Without Ordered Meal Timing: A resident with dementia and long-term drug therapy orders received carvedilol from an MA before eating, even though the blister packet said to take it with meals and the physician order specified administration with meals. The MA stated he did not read the packet instructions, and the DON and Administrator said meds were expected to be given according to the MAR and physician orders.
Unsecured Dumpster Door: The facility failed to keep the dumpster lids and doors secured for 1 of 1 dumpsters reviewed in Food and Nutrition Services. Surveyors observed a commercial-size dumpster behind the dietary department that was about 3/4 full of garbage with the door wide open. The dietary food manager and the DON/Administrator stated the dumpster should be kept closed to prevent vermin, pests, insects, waste spread, and infection.
Hand hygiene and PPE use were not followed during incontinent care for a resident with a Foley catheter and bowel incontinence. A CNA handled clean supplies, donned gloves without washing hands, provided perineal care, and changed gloves without washing hands between tasks. The resident had intact cognition, required staff help with ADLs, and was care-planned for Foley catheter cleansing and perineal hygiene.
The facility failed to ensure the dishwashing machine in the main kitchen was operating with functioning thermometers, leading to unverified sanitization temperatures. Despite the thermometers being non-functional for a week, the machine continued to be used for cleaning silverware and glassware. The Dishwasher Temperature Log showed no recorded temperatures for several weeks, contrary to facility policy and FDA guidelines.
A resident with Parkinson's Disease and other health issues did not receive timely incontinence care, leading to extended periods in soiled briefs. Despite a care plan requiring regular checks, the resident's call light often went unanswered, and staff interviews revealed communication breakdowns and non-adherence to care protocols. The DON acknowledged the risk of skin breakdown and UTIs from such delays.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week during July and August 2024, particularly lacking on weekends. The Administrator acknowledged the issue, citing difficulties in retaining RNs, although new hires were made at the end of August. The DON highlighted the importance of RNs for performing specific medical procedures and assessments that LVNs cannot, which was not met during the deficiency period.
The facility reported an 11% medication error rate, exceeding the acceptable 5% threshold. Errors included incorrect dosages of Nicotine gum and Acetaminophen, and an incorrect IV rate for Cefepime. These errors involved three residents and two staff members, highlighting issues with medication administration and verification processes.
The facility failed to implement its policies to prevent abuse, neglect, and exploitation of residents, as well as misappropriation of property. Background checks and EMR reviews for three staff members were not conducted annually as required, with delays of 24 to 28 months. The oversight was due to a lack of follow-up by the previous HR Director, and the current HR Director plans to conduct checks annually to ensure compliance.
Missed IV Antibiotics for Resident with PICC Line
Penalty
Summary
The facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for one resident who had a PICC line, an open right groin wound, severe cognitive impairment, chronic kidney disease, hepatitis C, respiratory failure with hypoxia, aneurysm, and congestive heart failure. The resident was admitted back to the facility on the evening of 5/5/26 after a hospital stay, and nursing documentation noted that medications were reconciled with the NP. Physician orders included Vancomycin HCl IV 500 mg twice daily for wound infection and Ampicillin-Sulbactam IV every 8 hours for wound infection, along with lab monitoring and PICC dressing changes. On 5/6/26, the MAR-TAR showed a code of 5 for both Vancomycin and Ampicillin-Sulbactam at 8:00 a.m., indicating hold/see progress notes. During observation that morning, the resident was in bed with an IV pole beside him, but there was no IV tubing, IV bag, or IV pump present. Later that afternoon, the resident again had a PICC line in the right upper arm and an IV pole with no tubing, bag, or pump. The resident stated staff were always late giving his IV antibiotics and said he had been back at the facility since the night before and still had not received any IV antibiotics. Staff interviews confirmed the medications were not available when needed. The Wound Care Nurse could not find the resident’s IV antibiotics in the medication storage room and said if a resident was admitted at night, the IV antibiotic would be at the facility by 10:00 a.m. the next day. An LVN stated the pharmacy could take 2 to 3 days to deliver medication and that she did not know the resident’s IV antibiotic was missing. The NP said he did not want the resident to go more than 24 hours without the antibiotic. The DON and ADM stated the nurse should have known about the antibiotics and followed up when they were not available, and the DON said the medication should have been delivered by 10:00 a.m. the next day.
Central line dressing change not performed using sterile technique
Penalty
Summary
The facility failed to ensure parenteral fluids were administered in accordance with physician orders, the care plan, and professional standards of practice for one resident with a right upper chest central line. The resident was admitted with diagnoses including hyperlipidemia, lobar pneumonia, acute kidney failure, essential hypertension, septic pulmonary embolism, and rhabdomyolysis, and his admission MDS reflected a BIMS score of 13, indicating intact cognition. Hospital discharge records showed the resident had a midline placement and was ordered meropenem 500 mg IV every 12 hours for 21 days for sepsis. The physician’s progress note ordered IV dressing changes on admission and weekly, but the care plan did not include instructions for maintenance of the right midline subclavian double lumen to be changed every Sunday and as needed. On observation, the resident was lying in bed with a central line in the right upper chest and dressings dated 11/20/25; both the dressing and tape were brownish in color. The resident stated the dressing had not been changed since admission. The ADON observed the line and stated the dressing should be changed every Sunday and as needed. Shortly afterward, an LVN entered the room and began the dressing change without washing hands, retrieved gloves from her uniform pocket, opened the sterile dressing package and placed it on the air conditioning vent by the bedside, removed the old dressing with difficulty, and used scissors from her pocket to cut off the dressing before cleaning around the IV site. During interview, the LVN stated she should have used sterile procedure for the IV change and acknowledged that her gloves and scissors were in her pocket. She said she had IV training but it had been over a year and that this was her first time working with the resident. She also stated that not following the correct technique could introduce infection and that the dressing change should have been done with sterile gloves, cleaning the site, allowing it to dry, and ensuring the line was secure. The DON stated the procedure was sterile, that PICC and midline training had been provided, and that PICC line dressings should be changed every 5 to 7 days with site observation every shift for redness, drainage, or heat.
Medication administration errors exceeded allowable rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified 11 medication errors out of 31 opportunities, resulting in a 35% error rate, involving four residents and two medication staff members reviewed for medication administration practices. The errors included omitted medications, incorrect doses, medications given at the wrong time, and medications not given with required food or fluids. Resident #55 had diagnoses including GERD, hyperlipidemia, pneumonia, acute kidney failure, and hypertension, and had a BIMS score of 13 out of 15. The resident’s record showed an order for Pantoprazole 40 mg by mouth daily, and a separate IV Pantoprazole order with a start date of 12/4/25. During observation, LVN C hung IV normal saline with a Pantoprazole vial attached, but the medication was not reconstituted back into the saline bag, so the resident was receiving only normal saline. The resident had already received oral Pantoprazole earlier that morning, and LVN C stated she did not know the IV Pantoprazole was not to start until the following day and was not aware the resident had already received the oral dose. Resident #53 had diagnoses including hypomagnesemia, COPD, malnutrition, CHF, diabetes with hyperglycemia, and hypotension, with a BIMS score of 13 out of 15. The physician ordered Magnesium Oxide 420 mg daily for hypomagnesemia. During medication pass, MA A prepared the resident’s medications but did not administer Magnesium Oxide as ordered, even though the MAR was initialed as given. Resident #5 had diagnoses including neuropathy, spinal stenosis, urinary retention, constipation, insomnia, anemia, hyperlipidemia, anxiety, UTI, diabetes with hyperglycemia, and muscle wasting and atrophy, with a BIMS score of 15 out of 15. The physician ordered Arginald packets twice daily for nutrient repletion and wound healing, but MA A prepared the medications and did not administer Arginald during the pass, while the MAR was also initialed as given. Resident #23 had diagnoses including muscle weakness, insomnia, GERD, vitamin deficiency, dysphagia, multiple sclerosis, unspecified dementia, and anxiety, with a BIMS score of 14 out of 15. The physician ordered Acyclovir with food and extra fluid, Baclofen 30 mg three times daily, Carvedilol with food, Trazodone shortly after a meal or light snack, Gabapentin at bedtime, Donepezil in the evening, lubricating eye drops twice daily, and Acetaminophen 650 mg three times daily. During observation, MA B administered Acyclovir without the required food and fluid, gave Baclofen 10 mg instead of 30 mg, gave Carvedilol without food, did not give Trazodone with a meal or snack, did not administer Acetaminophen or lubricating eye drops despite initialing them as given, and gave Donepezil and Gabapentin at 4:00 p.m. instead of the ordered evening/bedtime times. MA B stated that timing depended on the individual and the MAR, and the DON stated staff should clarify orders with the charge nurse if the order did not appear correct or the amount did not match the order.
Food Storage and Meal Temperature Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and for residents receiving meals. During kitchen observation, surveyors found leftover gravy, Italian gravy, and potato casserole stored with used-by dates of 11/26/25 and 11/30/25. The dietary manager stated leftover food saved for later was to be labeled with a used-by date, stored in the refrigerator for 5 days, and then discarded, and also stated he was responsible for training staff on labeling and storage requirements. During meal observation, three food sample trays brought into the conference room had temperatures below hot-holding standards: a chef salad at 63 F, a hamburger at 68 F, and spaghetti with meat sauce at 63.2 F. The heated bases under each plate were cold to the touch. Several residents stated their food was served cold, including reports that meals were unpalatable, sometimes late by 30 to 45 minutes, and often eaten in their rooms. The dietary manager stated food should be cooked according to recipe and served hot and appealing, that staff were responsible for following recipes and ensuring heated bases were plugged in, and that he monitored staff by spot checks. Grievance logs also showed complaints about cold food on multiple occasions.
Failure to Provide Proper Foley and Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent and Foley catheter care for a resident with intact cognition who required staff assistance with ADLs and was care-planned for a Foley catheter and incontinent care. The resident’s diagnoses included benign prostatic hyperplasia, acute kidney failure, hypertension, muscle weakness, gait and mobility abnormalities, and other conditions. His care plan included total dependence for personal hygiene and toilet use, and physician orders directed daily and as-needed Foley catheter cleansing and perineal hygiene with a catheter securing device. During observation of Foley catheter and incontinent care, CNA A did not put on a gown and did not change gloves while cleaning the resident’s Foley catheter tubing and penis. CNA A also did not clean the resident’s scrotum and buttocks before placing a clean brief under him. In an interview, CNA A stated she did not clean the buttocks because she did not want the dressing on that site to come off, and she acknowledged that not cleaning the buttocks could cause more skin break and odors. The facility’s incontinent care policy stated that male incontinent care should include cleansing the penis shaft and scrotum, cleaning the legs and turning the resident to repeat on the back side, and removing gloves and washing hands. The same policy stated incontinent care should be provided in a manner that ensures no cross contamination. The observed care did not follow those steps.
Improper Tracheostomy Care and Suctioning
Penalty
Summary
The facility failed to ensure proper tracheostomy care and suctioning for a resident with a tracheostomy. Resident #32 was admitted with diagnoses including tracheostomy status, acute respiratory failure with hypoxia, dysphagia, muscle weakness, hypertension, prostate cancer, and other chronic conditions. His care plan addressed his tracheostomy and routine equipment maintenance, and physician orders directed tracheostomy care, suctioning every shift and as needed, and documentation of suctioning performed during the shift. During observation, LVN B provided tracheostomy care and suctioning while the resident was in bed with audible moist breath sounds and the tracheostomy covered with a cap. LVN B wore clean gloves initially but did not set up a clean field, removed dirty gloves without washing hands, opened the sterile trach care kit, and handled the suction equipment and trach supplies in a manner that did not maintain sterile technique. She suctioned the resident twice, but did not remove the inner cannula to clean or replace it and did not clean the surrounding trach site. The resident was coughing up a significant amount of phlegm during suctioning, and oxygen saturation was not checked. In interview, LVN B stated she did not wash her hands during trach care or suctioning and acknowledged she should have used sterile technique throughout. She said she had recently been in-serviced on tracheostomy care but could not recall the date, and stated that not using sterile technique placed the resident at risk for respiratory infection. The DON stated LVN B had been in-serviced on tracheostomy care and should have used sterile technique, and confirmed that failure to do so could place the resident at risk for infection. The facility policy required aseptic technique and sterile gloves during endotracheal suctioning and tracheostomy care as ordered.
Late Administration of Ordered Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #42 by not administering acetaminophen at the physician-ordered time. Resident #42 was an [AGE] year-old female with diagnoses including dementia, generalized anxiety disorder, depression, muscle wasting and weakness, and chronic left shoulder pain. Her order summary and individual order showed acetaminophen 500 mg by mouth three times daily for arthritis, scheduled for 8:00 a.m., 1:00 p.m., and 5:00 p.m., and the MAR for 12/02/2025 showed the 8:00 a.m. dose had not been administered by 9:05 a.m. The medication was delivered at 9:45 a.m., later than the ordered time. Resident #42 stated on 12/01/2025 that she did not receive her pain medication on time in the morning and that medication was sometimes delivered late. On 12/02/2025, she said she did not think she had received her medications that day. The MA stated medication could be given one hour before and one hour after the ordered time and said she was still administering medications in another hall and had not yet given Resident #42's medications. The DON later stated the delay occurred because the MA spent extra time obtaining other residents' blood pressures, and the facility policy stated medications must be administered within one hour of the prescribed time unless otherwise specified.
Failure to Communicate Pharmacist Medication Irregularity
Penalty
Summary
The facility failed to send a pharmacist-identified medication irregularity to the attending physician, the facility’s medical director, and the director of nursing for Resident #23. The deficiency involved the monthly drug regimen review process and the facility’s handling of a pharmacist recommendation related to Baclofen. Record review showed Resident #23 was a 72-year-old female with diagnoses including multiple sclerosis, muscle weakness, muscle wasting and atrophy, difficulty walking, insomnia, major depressive disorder, constipation, vitamin D deficiency, anxiety, unspecified dementia, and fractures of the left tibia and fibula. Her quarterly MDS reflected a BIMS score of 14 out of 15, indicating intact cognition. Resident #23 had a physician order for Baclofen 10 mg, 3 tablets (30 mg) by mouth three times daily for muscle spasm, and the MAR reflected the same order. The pharmacist’s review identified Baclofen 30 mg TID as requiring attention and stated the medication should be evaluated and the desire to use a muscle relaxer verified, noting CMS considers the medication inappropriate for use and describing concerns such as anticholinergic side effects, sedation, increased risk of fractures, and weakness. The record review of progress notes showed no documentation that the physician or DON were aware of the pharmacist’s review. During interview, the DON stated she was not aware of the pharmacist’s recommendation and was seeing it for the first time. She said the former ADON had been responsible for notifying the doctor about the recommendation and stated that not following the recommendation could cause drug overdose and falls. The facility policy required the consultant pharmacist to provide written reports of irregularities to physicians, and to provide the DON and medical director with signed and dated copies of the report listing irregularities and recommendations.
Medication Given Without Ordered Meal Timing
Penalty
Summary
Resident #23, a 72-year-old female with diagnoses including long term drug therapy and unspecified dementia, had a physician order for carvedilol 3.125 mg by mouth three times a day for blood pressure with meals, with hold parameters for SBP and HR. During an observation, MA B prepared and administered carvedilol 3.125 mg from a blister packet that instructed the medication to be taken with a meal, even though Resident #23 had not yet eaten and the dinner tray was not expected until later. MA B stated he did not read the blister packet instructions and apologized when shown that the medication was to be given with meals. In interview, the DON stated that staff should clarify any order that did not appear correct before administering the medication and that the amount administered did not match the order and the order was not clear. The DON also stated staff were expected to use the MAR to administer medications and not change medication times at their own or the resident's convenience, but to follow physician orders. The Administrator stated that nursing staff were expected to give medications timely, correctly, and according to physician orders.
Unsecured Dumpster Door
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for Food and Nutrition Services because the dumpster lids and doors were not secured. Observation on 12/05/2025 at 8:45 a.m. revealed the dumpster area behind the dietary department had a commercial-size dumpster that was about 3/4 full of garbage and the door was wide open. In an interview on 12/05/2025 at 9:20 a.m., the dietary food manager stated that dumpster doors must be closed to keep vermin, pests, and insects out of the dumpster from entering the facility. In an interview with the DON and Administrator on 12/02/2025 at 5:00 p.m., the Administrator stated the dumpster should not have been open and said waste could come out of the dumpster and animals could come in and spread the trash and infection around. Record review of the facility waste disposal policy stated that food-related garbage and rubbish is disposed of in accordance with current laws and regulations and that the outside dumpster will be kept closed and free of surrounding litter.
Hand Hygiene and PPE Not Followed During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA A did not perform hand hygiene before donning gloves for incontinent care and did not wash hands between glove changes during care for a resident with a Foley catheter and bowel incontinence. During observation on 12/02/25 at 5:04 PM, CNA A did not don PPE before handling clean supplies, placed a cleaned brief and wet wipes on the resident’s bed, donned clean gloves without washing hands, and provided perineal care to the resident’s penis, Foley catheter tubing, and groin. CNA A then placed a clean brief under the resident, changed gloves without washing hands, and donned clean gloves again. Resident #55 was an adult male admitted to the facility with diagnoses including acute kidney failure and benign prostatic hyperplasia with lower urinary tract symptoms. His admission MDS showed a BIMS score of 13 out of 15, indicating intact cognition, and he required staff assistance with ADLs. The care plan identified him as totally dependent for personal hygiene and toilet use and included Foley catheter cleansing and perineal hygiene daily and as needed. CNA A stated in interview that she only wears PPE while assisting nurses with dressing changes and said she had received in-service training on PPE use, but she forgot to wash her hands.
Dishwashing Machine Temperature Monitoring Deficiency
Penalty
Summary
The facility failed to maintain the dishwashing machine in the main kitchen in accordance with professional standards for food service safety. During an observation and interview, it was noted that the thermometers on the low-temperature dishwashing machine were not functioning, and had not been working for a week. Despite this, the machine was still in use for cleaning silverware and glassware. The Dining Supervisor mentioned that the dishwashing company had visited two weeks prior but did not address the issue, and there was uncertainty about any documentation from that visit. The Chef acknowledged that without a working thermometer, the kitchen staff could not verify if the machine was reaching the necessary temperatures for sanitization. The facility's Dishwasher Temperature Log showed no recorded wash or rinse temperatures from the beginning of the month until the day of the observation, indicating a lack of monitoring. The facility's policy requires that dishwashing machines using hot water for sanitization must maintain specific temperatures, and operators are to record these temperatures with each cycle. The policy also mandates immediate cessation of machine use if temperatures or chemical sanitation concentrations do not meet requirements. The U.S. Food and Drug Administration Food Code specifies minimum wash solution temperatures for machines using chemical sanitizers, which were not being verified due to the malfunctioning thermometers.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was unable to perform activities of daily living independently. The resident, a female with a history of muscle weakness, osteoporosis, and Parkinson's Disease, was dependent on staff for assistance with toileting and personal hygiene. Despite having a care plan in place that required regular checks and changes to prevent skin breakdown, the resident reported that her call light often went unanswered for hours, and she had not been changed since 3:00 am on the day of the interview. The resident expressed that she frequently had to wait for extended periods to be changed and felt that reporting the issue did not result in any improvement. Interviews with facility staff revealed a breakdown in communication and adherence to care protocols. A CNA admitted to not having time to change the resident due to other duties and claimed to have informed a nurse, who denied receiving such information. The nurse stated that CNAs were expected to round every 2 hours and change residents as needed, and if unable, they should inform a nurse who would assist. The DON confirmed that residents should not wait more than 30 minutes for care and acknowledged the risk of skin breakdown and UTIs if residents remained in soiled briefs for extended periods. The facility's policy emphasized the importance of providing necessary care to maintain residents' hygiene and prevent complications, which was not adhered to in this case.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week during the months of July and August 2024. This deficiency was identified through interviews and record reviews, revealing that the facility did not have an RN on duty during weekends for these months. The Administrator acknowledged the lack of RN coverage on weekends, citing difficulties in retaining RNs, although she had recently hired an RN Supervisor and an RN floor nurse at the end of August. The Director of Nursing (DON) confirmed that she worked Monday through Friday and emphasized the importance of having RNs on-site due to their ability to perform specific medical procedures that Licensed Vocational Nurses (LVNs) cannot, such as removing PICC lines and placing suprapubic catheters. The absence of RNs was noted to potentially put residents at risk due to the lack of advanced assessment skills and procedures that RNs provide. The facility's policy stated the requirement for RN coverage, but the staffing records submitted to the CMS payroll-based journal system did not reflect compliance with this requirement during the specified months.
Medication Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 11% error rate. This was due to three medication errors involving three residents and two staff members. The errors included incorrect dosages and administration rates, which were observed during a survey. One error involved a resident who was supposed to receive Nicotine gum 4 mg every four hours but was given a 2 mg dose by a medication aide. The aide admitted to not concentrating on the dose due to a busy medication pass. The Director of Nursing (DON) noted that the facility had 2 mg gum on hand and the aide should have clarified the dosage. Another error involved a resident who was prescribed Acetaminophen 650 mg but was given two 325 mg tablets instead. The medication aide misunderstood the dosage instructions on the Medication Administration Record (MAR). Additionally, a resident receiving Cefepime IV was administered the medication at an incorrect rate due to a miscalculation by the LVN, who did not verify the bag size. The DON and other staff acknowledged the errors and the need for clarification in such situations.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified for three staff members (LVN C, LVN D, and LVN E) whose background checks and EMR reviews were not conducted annually as required by the facility's policies. The facility's policy on Background Screening Investigations mandates employment background screening checks, reference checks, and criminal conviction investigation checks on all applicants for positions with direct access to residents. However, the records showed that these checks were not performed annually for the staff members in question, with delays ranging from 24 to 28 months. Interviews with the Human Resources Director and the Administrator revealed that the oversight occurred due to a lack of follow-up on the part of the previous Human Resources Director, who no longer worked at the facility. The current Human Resources Director, who started after the oversight, acknowledged the lapse and planned to conduct checks at the beginning of each year to ensure compliance. The Administrator was unaware of the missed checks and could not provide an explanation for the oversight. This failure to adhere to the facility's policies could place residents at risk of abuse, neglect, and misappropriation of property.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
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| Ffiii Houston Snf Tenant Llc | 1 mi | ★★★★★ | 0 | 0 |
| Woodway Nursing & Rehab | 1.6 mi | — | 14 | 2 |
| The Lev At Town Park | 2 mi | ★★★★★ | 2 | 2 |
| Sharpview Residence And Rehabilitation Center | 2.1 mi | ★★★★★ | 1 | 0 |
| The Vosswood Nursing Center | 2.2 mi | ★★★★★ | 0 | 0 |
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