Whispering Pines Lodge
Inspection history, citations, penalties and survey trends for this long-term care facility in Longview, Texas.
- Location
- 2131 Alpine Rd, Longview, Texas 75601
- CMS Provider Number
- 675386
- Inspections on file
- 36
- Latest survey
- February 20, 2026
- Citations (last 12 mo.)
- 35 (8 serious)
Citation history
Health deficiencies cited at Whispering Pines Lodge during CMS and state inspections, most recent first.
A resident with multiple cardiac and cognitive comorbidities, on a mechanically altered diet, began choking while eating in the dining room. An LVN responded by lightly patting the resident’s back, but appropriate back blows and the Heimlich maneuver were not performed for over a minute as the resident progressed to unresponsiveness. Additional staff, including an RN and a medication aide, then attempted the Heimlich on the now-limp resident and performed a sternal rub before moving the resident to a nearby room, delaying CPR initiation by about two minutes. Review showed the resident’s care plan did not address choking risk, the facility’s choking policy lacked guidance for when a resident becomes unconscious, and the LVN, RN, and medication aide involved did not have current BCLS certification, contrary to facility policy requiring current CPR/BCLS training.
The facility failed to ensure residents had access to warm water for bathing and showers, resulting in at least one resident receiving a cold bed bath during a winter storm and another receiving a cold shower when hot water was unavailable. A resident with fractures and chronic diastolic heart failure, who required substantial assistance with bathing, reported taking a cold bed bath when the facility lost power and had no warm water. Staff, including a SW, CNA, LVN, housekeeping staff, and supervisors, described ongoing problems with cold water on one hall, residents refusing showers, and staff transporting residents to other halls or carrying hot water between showers. A surveyor measured the shower water at 71°F on the affected hall, and the area maintenance specialist later found the hot water temperature had been turned down and that required weekly water‑temperature logs had not been completed for several weeks, despite a policy requiring water temperatures of 100–110°F and resident rights to care that promotes quality of life.
A resident with severe cognitive impairment, multiple neuropsychiatric diagnoses, and total dependence for ADLs was observed seated in a wheelchair near the nurse’s station with a white liquid spilled on his pants and on the floor beneath him for an extended period while staff walked past without changing his clothing. Although the spill on the floor was eventually cleaned, the resident’s pants remained visibly wet until later, when a CNA and a COTA used a mechanical lift to provide care and change his clothes, at which time the wheelchair and lift sling were also found to be wet. In interviews, CNAs, a CMA, an LVN, the ADON, the DON, and the administrator all acknowledged that all staff are responsible for keeping residents clean and dry and that leaving a resident in soiled clothing is a dignity issue, consistent with the facility’s Resident Rights policy.
A resident with COPD, acute respiratory failure, anxiety disorder, myopathy, and moderate cognitive impairment was observed sitting in her room with a prescribed Fluticasone Propionate nasal spray left on her bedside tray instead of being secured. The resident reported that staff usually kept the medication locked. A CMA admitted she had given the nasal spray, left the room, and later realized she had failed to return it to the med cart. Facility staff, including CMAs, an LVN, the ADON, the DON, and the administrator, all stated that residents were not permitted to have medications in their rooms, that no residents were authorized to self-administer medications, and that nursing staff were responsible for proper medication storage, in contrast to what occurred in this case.
Surveyors identified that staff failed to follow infection control practices for handling and storing trash and soiled linens in one hall and two shower rooms. Dirty linens were left on shower floors, trash bags were placed on the floor in a hallway and behind a shower door, and a staff member handled soiled linens without gloves. Trash was stored in clear bags and transported on top of gray linen barrels instead of in designated yellow barrels. Multiple CNAs, CMAs, housekeeping staff, the housekeeping supervisor, ADON, DON, and the administrator all acknowledged that these practices violated facility policy requiring proper containment, use of PPE, and appropriate transport of trash and linens to prevent contamination.
Surveyors identified that dirty linens were left on a shower floor, trash bags were stored on the floor in a hall and behind a shower door, and a toilet rim in a shower room remained broken with exposed porcelain edges. Staff interviews showed that facility expectations and policies required dirty linens to be bagged and placed in gray barrels, trash to be contained in yellow barrels, and no trash or linens to be stored on floors or behind doors. One CNA acknowledged placing trash bags on the hallway floor and misunderstanding that this was acceptable if bagged. A housekeeper reported the broken toilet months earlier via a maintenance system, while nursing and administrative staff, including an LVN, ADON, DON, and ADM, stated they were unaware of the damage and that any staff member who found such issues was responsible for reporting them immediately, consistent with the facility’s infection control and resident rights policies.
Surveyors identified multiple instances of abuse, neglect, and inadequate care, including a nurse physically abusing a resident with severe cognitive impairment, another nurse verbally abusing a resident and refusing pain medication, and repeated resident-to-resident altercations resulting in injury. Additional deficiencies included improper positioning during tube feeding leading to aspiration, lack of wound care, insufficient feeding assistance, and inadequate supervision due to staffing shortages. Staff interviews confirmed ongoing concerns about inadequate staffing and lack of support.
Multiple residents experienced unwitnessed falls and resident-to-resident altercations due to inadequate supervision and insufficient staffing, with only one staff member often present on the secured unit. Staff interviews and observations confirmed that residents were frequently left unsupervised in common areas, and care plans did not consistently address fall risks or behavioral issues, resulting in injuries and unmonitored incidents.
A facility failed to provide adequate nursing staff with the necessary skills to meet resident needs, resulting in missed care interventions such as improper positioning during tube feeding that led to aspiration pneumonia, and incomplete wound care and documentation for multiple residents with complex medical conditions. The secured unit also lacked sufficient staff to prevent accidents and provide supervision during mealtimes, contributing to ongoing deficiencies in resident care and safety.
A resident with multiple comorbidities experienced repeated episodes of abnormal vital signs, including low blood pressure and heart rate, resulting in held antihypertensive medications over several days. Despite facility policy requiring physician notification for such changes, there was no consistent documentation or evidence that the physician was informed, and staff interviews revealed confusion about notification responsibilities. The resident was later hospitalized for a gastrointestinal hemorrhage after critical lab values were discovered.
A resident with severe cognitive and physical impairments, dependent on staff for all care, was left leaning over the armrest of a Geri-chair for an extended period during tube feeding, contrary to care plan and physician orders requiring head elevation. Despite a CNA's brief attempt to reposition, the resident remained improperly positioned until a nurse intervened much later. The incident resulted in aspiration, confirmed by hospital evaluation, and staff interviews cited inadequate staffing as a factor in the failure to provide appropriate monitoring and care.
Two residents experienced unmanaged pain due to missed and delayed administration of scheduled opioid and non-opioid pain medications, lack of required pain assessments, and failure to offer alternative or non-pharmacological interventions as ordered. Staff did not consistently document pain assessments or notify physicians when doses were missed, and PRN pain medications were not administered when residents displayed signs of pain during care. These actions were not in accordance with professional standards or the facility's pain management policy.
During a COVID-19 outbreak, the facility did not ensure staff consistently used required PPE, such as N-95 masks and face shields, when caring for residents with confirmed infections. PPE carts lacked necessary supplies, and staff were observed entering and exiting rooms without changing masks or performing hand hygiene due to missing sanitizer. Isolation signage was absent from affected residents' doors, and new symptomatic residents were not promptly tested. Facility leadership was unaware of these lapses, and infection control protocols were not properly followed or monitored.
A resident with chronic pain and mental health diagnoses did not receive scheduled pain medications on time and, during a subsequent interaction, an LVN spoke to her in a disrespectful and condescending manner, including raising her voice and using inappropriate gestures. A CNA witnessed the incident and confirmed the LVN's tone was not respectful. Facility leadership acknowledged that this conduct violated the resident's rights to dignity and respectful communication.
A resident with chronic pain conditions did not receive proper protection from misappropriation of her prescribed Oxycodone when staff documented an extra dose that was not administered, and the discrepancy could not be reconciled through medication records or staff interviews. The incident involved inconsistent documentation, staff concerns about possible drug diversion, and a lack of clear explanation from the nurse responsible.
The facility did not thoroughly investigate allegations involving two residents, including possible misappropriation of narcotic medication and failure to administer pain medication as requested. Despite reports from staff and family, there was no evidence of comprehensive investigation or immediate protective actions, and the nurse involved continued to work with residents after the incidents.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
A resident with spastic quadriplegic cerebral palsy and chronic kidney disease was not permitted to use his personal motorized wheelchair during his stay, despite prior use and intact cognition. Facility staff cited an outdated practice of disallowing motorized wheelchairs, and the resident was not assessed for safe use as required by policy. This resulted in the resident's loss of independence and increased reliance on staff for mobility.
An oxygen cylinder was found stored upright on the floor in a resident's room, rather than in a caddy or secured area as required by facility policy. The resident, who had multiple serious medical conditions, was present in the room with the unsecured tank. Staff interviews confirmed that the tank should have been properly stored to prevent accidents, and the facility's policy prohibits leaving cylinders free-standing.
A resident with severe cognitive and physical impairments was unable to call for staff assistance due to a non-functional call light, which had been inoperative for approximately two weeks. The issue was only discovered during a surveyor's visit, with the resident's roommate confirming the ongoing problem and staff acknowledging that maintenance had not been notified. Facility records indicated that routine checks had not identified the issue prior to the survey.
A resident with severe cognitive impairment and a history of wandering eloped from a secured unit in an LTC facility. The resident was found at a local hospital after being taken there by police. The facility was unaware of the resident's absence for four hours. The resident had previously demonstrated exit-seeking behavior, and staff were not aware of the resident's ability to disable window alarms and remove thumb locks, leading to the elopement.
A resident with Huntington's Disease was improperly restrained by a CNA in a LTC facility, violating resident rights. The CNA tied the resident's legs to the bed using leggings, despite having received training on the facility's restraint-free policy. The incident was discovered by another CNA, leading to an investigation by the facility's administration.
Two residents in a facility were involved in separate incidents due to inadequate supervision and failure to follow safety protocols. One resident, with severe cognitive impairment, was found with an unattended spray bottle of cleaner, suggesting possible ingestion. Another resident, requiring dialysis, was not properly secured in a transport van, resulting in a fall and head abrasions. The facility failed to ensure proper training and adherence to safety procedures, leading to these deficiencies.
The facility failed to ensure proper management of psychotropic medications, including gradual dose reductions and behavioral interventions, for several residents. One resident experienced lethargy, falls, and weight loss due to medication side effects, and the facility did not notify the physician of significant weight loss or accurately report behaviors. Additionally, PRN Lorazepam use was not limited to 14 days for other residents, lacking necessary documentation for extended use, placing residents at risk for adverse side effects.
The facility failed to accurately complete PASRR Level I screenings for four residents, omitting diagnoses of mental illnesses such as PTSD and major depressive disorder. This oversight could prevent residents from receiving necessary assessments and specialized services. Interviews with staff revealed a lack of awareness regarding the need to update PASRR screenings upon admission or re-admission with mental health diagnoses.
The facility failed to provide meaningful activities for residents in the memory care unit, as observed during a survey. Despite having an activity schedule, no dementia-focused activities were implemented, and the activity director was infrequently present. Staff reported that the lack of activities might contribute to falls and incidents, and the absence of a specific activity calendar for the memory care unit was noted.
Three residents experienced inadequate hydration due to insufficient fluid intake and inconsistent staff practices. One resident with multiple sclerosis reported a dry mouth, another with cerebral infarction had to request water, and a third with Alzheimer's had elevated BUN levels. Staff interviews revealed dissatisfaction with the hydration system, highlighting potential health risks.
The facility failed to provide adequate pharmaceutical services, resulting in missed medication doses and improper administration for several residents. A resident did not receive Niacin, Ativan, and Nicotine Patch due to unavailability, while another received crushed Aspirin EC against orders. Two other residents experienced medication shortages, with Lorazepam and Lomotil not being available. Staff interviews revealed communication issues with the pharmacy and inadequate emergency kit stocking.
A facility reported a medication error rate of 61.76%, involving late administration and incorrect dosing for residents with complex medical conditions. Errors included late administration of anxiety and pain medications, incorrect IV infusion rates, and failure to apply a prescribed patch. Staff interviews revealed issues with adherence to medication schedules and physician orders.
Two residents received losartan despite vital signs being outside prescribed parameters. Staff interviews revealed a lack of adherence to medication protocols, with MAs administering medication based on nurse instructions. The facility's policy emphasizes the ten rights of medication administration, but these were not followed, risking adverse effects.
A facility failed to provide a baseline care plan to the responsible party (RP) of a resident with severe cognitive impairment and multiple diagnoses. Although the resident received a copy, the RP did not, which could lead to a lack of understanding of the care being provided. Interviews with staff revealed inconsistencies in executing the responsibility of providing the baseline care plan to the RP, despite the facility's policy requiring it.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. A resident's care plan did not include her prescribed psychotropic medication, another resident's behavioral symptoms were not addressed, and a third resident's limited range of motion and music preferences were omitted. Staff interviews highlighted the importance of care planning to ensure residents' needs and preferences are met.
The facility failed to provide scheduled baths for three residents, leading to missed hygiene care. A resident with cerebral palsy and heart failure, another with severe cognitive impairment, and a third with Alzheimer's disease did not receive baths as per their care plans. Documentation was lacking, and staff turnover was cited as a reason for the missed baths.
A resident with COPD and other health issues was found to have an oxygen concentrator with a 90% missing filter, which was not replaced as required by facility policy. Interviews revealed that the facility had procedures for maintaining clean and functioning filters, but these were not followed, potentially exposing the resident to respiratory risks.
The facility failed to ensure the safe and sanitary storage of food in the personal refrigerators of two residents. One resident had expired protein drinks, while another's refrigerator contained a brown and black substance with dead gnats. Despite the facility's policy requiring family or staff to maintain cleanliness, there was confusion among staff about their responsibilities, leading to unsanitary conditions and potential health risks for the residents.
A facility failed to maintain an effective infection prevention and control program, as a medical assistant entered and exited a COVID-19 positive resident's room wearing only a surgical mask instead of the required full PPE. The resident, with multiple health conditions, was on isolation precautions. Despite clear signage and staff understanding of PPE protocols, the assistant did not adhere to them, risking cross-contamination and infection spread.
The facility failed to report the results of an investigation into an alleged abuse incident between two residents to the state survey agency within the required timeframe. The administrator admitted to forgetting to send the report, despite being solely responsible for its submission. The facility's policy mandates that such reports be sent within 5 working days, which was not followed in this instance.
Failure to Provide Timely BLS/CPR and Appropriate Choking Response
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support (BLS), including CPR and appropriate choking interventions, to a resident in distress prior to EMS arrival, in accordance with AHA/BCLS guidelines, physician orders, and the resident’s advance directives. The resident was an elderly female with diagnoses including senile degeneration of the brain, CHF, type 2 diabetes, atrial fibrillation, respiratory failure, muscle weakness, and a cardiac pacemaker. Her MDS indicated severe cognitive impairment, need for assistance with eating and mobility, incontinence, and a mechanically altered diet. Her care plan noted a diet other than regular but did not address choking risk. On the morning of the incident, video footage showed the resident seated in the dining room in a wheelchair, eating breakfast when she began to choke. LVN A responded promptly after the resident gestured to her back, and LVN A began lightly tapping the resident’s back. The resident violently shook her head "no" and later appeared to vomit, then nodded "yes". LVN A continued lightly patting the resident’s back and appeared to yell for help. The resident’s body then became limp and unresponsive while still in the wheelchair. LVN A briefly left toward the edge of the dining room, then returned, and RN B entered the dining room. LVN A resumed lightly patting the resident’s back, then positioned the resident’s limp body forward with her head on the table and began more aggressive back patting. During this period, appropriate back blows and the Heimlich maneuver were not performed for over a minute while the resident was in distress and then unresponsive. MA C then attempted the Heimlich maneuver while the resident remained limp in the wheelchair, followed by RN B attempting the Heimlich maneuver after the wheelchair was moved away from the table. RN B also attempted to shake the resident’s shoulder while MA C appeared to perform a sternal rub. Staff then pushed the resident in the wheelchair out of the dining room toward a nearby room to initiate CPR. The facility’s own timing and observations indicated that CPR initiation was delayed by approximately two minutes after the resident became unresponsive. The facility’s choking/aspiration policy addressed signs of choking and use of the Heimlich maneuver, including abdominal thrusts if the resident was on their back, but did not address what to do if the resident became unconscious or non-responsive. The facility’s CPR policy required at least one staff member trained in CPR/BCLS at all times and that trained staff maintain current certification. Record review showed that LVN A’s BCLS certification had expired, RN B’s BCLS certification had expired, and MA C was not currently certified in BCLS. Interviews confirmed that LVN A believed back slapping was the right action when she suspected choking and that she was scared and felt the event "felt like an eternity". RN B reported that when she arrived the resident was already blue and purple and unresponsive, that she checked the code status, called 911, and then attempted the Heimlich maneuver even though the resident was unconscious, acknowledging she panicked and knew CPR should be initiated when a choking victim becomes unresponsive. These actions and inactions—failure to promptly perform appropriate back blows and Heimlich on a conscious choking resident, failure to initiate CPR immediately once the resident became unresponsive, and allowing staff to work with expired or absent BCLS certifications—resulted in the resident not receiving basic life support while choking and constituted the cited deficiency.
Removal Plan
- Conduct an audit of all residents who expired in the facility during the last 30 days to ensure CPR was performed according to AHA/BCLS guidelines, including the Heimlich maneuver.
- Conduct an audit of all charge nurses for current CPR/BCLS certifications.
- Provide CPR/BCLS classes for all charge nurses to ensure current certifications, including return demonstration of skills (including the Heimlich maneuver).
- Provide 1:1 in-service training for the Administrator and ADON (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines.
- Provide 1:1 in-service training for LVN A, RN B, and MA C (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines.
- Notify the Medical Director of the Immediate Jeopardy citation.
- Hold an ADHOC QAPI meeting to review the Immediate Jeopardy citation(s) and the plan of removal.
- In-service all medication aides and CNAs (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect) and Notification of change in condition (universal signs of choking and immediate Heimlich per AHA/BCLS; notify nurse; respond immediately); prohibit staff from working their next shift until completed; include new hires during orientation and agency staff prior to shift.
- In-service all charge nurses (with post-test) on: Abuse and Neglect policy (including failure to perform Heimlich/CPR timely as potential neglect), Notification of change in condition (universal signs of choking and immediate Heimlich per AHA/BCLS), Cardiopulmonary Resuscitation (initiate CPR immediately when unresponsive with no pulse), and Choking/Heimlich per AHA/BCLS guidelines; prohibit staff from working their next shift until completed; include new hires during orientation and agency staff prior to shift.
Failure to Ensure Warm Water for Resident Bathing and Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with warm water for bathing and showers, resulting in cold bed baths and showers for at least two residents. One resident, an older female with fractures of the right tibia and fibula and chronic diastolic heart failure, had an admission MDS showing moderate cognitive impairment and a need for substantial assistance with bathing and total assistance with lower body dressing. Her care plan indicated she required two staff for bathing and that staff could provide a sponge bath when a full bath or shower could not be tolerated. She reported that during a winter storm, when the facility lost power and did not have warm water, she received a cold bed bath because she wanted to feel clean. A social worker reported that the Hall A shower water was cold and stated she discovered this when she stayed in the facility over a winter storm weekend and attempted to take a shower. She said she did not think the facility was aware of the cold water until she tried to shower. On observation, the Hall A shower water was run for approximately three minutes and measured 71°F, never reaching the recommended 100–110°F. The social worker stated that six residents resided on Hall A and were using Hall B and D showers until the water was fixed, without specifying a timeframe for repair. An anonymous resident reported receiving a cold shower because the facility did not have hot water. Multiple staff interviews showed ongoing awareness of hot water problems on Hall A (and at times Hall B) without consistent resolution or documentation. A CNA stated she knew the Hall A shower water was cold for 1–2 months, had reported it to maintenance and the DON, and that no one was taking showers in the Hall A shower room. Housekeeping staff and the housekeeping supervisor reported hearing CNAs complain about cold water, residents refusing showers, and staff having to take residents to other halls or carry hot water from one shower to another. An LVN reported that Hall A did not have hot water on and off, that residents had complained about not having hot water for hot beverages or to sponge off at their sinks, and that residents were taken to other halls for showers. The ADON and DON both stated that staff were expected to report water temperature issues immediately and ensure comfortable water temperatures, and the administrator acknowledged concerns with water not getting as hot as it should. When the area maintenance specialist was interviewed, he stated he was not aware that Hall A water was running cold and noted that the prior maintenance man had been terminated. On testing with the facility’s thermometer, the Hall A shower water measured 98.7°F and the sink water was warm, and he stated that somehow the hot water temperature had been turned down. He presented temperature logs and stated the expected range was 100–110°F, but the last recorded weekly temperature checks were dated more than a month earlier, with no logs documented since. Facility grievance records over a several‑month period did not show any complaints about water temperature. The facility’s resident rights policy required care in a manner and environment that promotes or enhances quality of life, and a facility checklist required weekly testing and logging of hot water temperatures in resident rooms and showers to ensure they remained between 100°F and 110°F, but these checks were not documented as completed during the period when residents and staff reported cold water and residents received cold baths and showers.
Resident Left in Soiled Clothing for Extended Period, Violating Dignity
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s dignity by allowing him to remain in soiled clothing for an extended period and to be taken toward the dining hall without timely changing his clothes. The resident was an elderly male with unspecified dementia, epilepsy, schizophrenia, major depressive disorder, and cerebrovascular disease. His MDS showed a BIMS score of 5, indicating severe cognitive impairment, and he was wheelchair-bound and dependent on staff for bed mobility, transfers, dressing, and toileting, requiring 1–2 staff assistance and a mechanical lift per his care plan. On the morning in question, surveyors observed the resident seated in his wheelchair in front of the nurse’s station with a clear cup of white liquid spilled on his dark gray pants at 8:50 a.m. At 9:15 a.m., he remained in the same location with the white liquid still on his pants and a small puddle of the substance under his wheelchair, while multiple staff members walked past him and sat at the nurse’s station. At 9:23 a.m., the resident was still in front of the nurse’s station with the absorbed white substance visible on his pants and under his wheelchair. By 9:51 a.m., the spill on the floor had been cleaned, but the resident’s pants still had a wet area on the left upper thigh. Later that morning, at 11:45 a.m., a CNA wheeled the resident toward the dining hall, stating his pants were dry but then took him to his room to change his clothing. At 11:55 a.m., the CNA and a COTA used a mechanical lift to transfer the resident, provided incontinent care, and changed his clothes. During this process, surveyors observed a white substance on the wheelchair and noted the lift sling was wet, requiring a clean sling before transferring the resident back. In interviews, the CNA reported she had gotten the resident up, dressed, and fed breakfast earlier, believed he had a health shake, and acknowledged that aides were responsible for ensuring he was clean and dry. Other staff, including a CMA, CNA, LVN, ADON, DON, and the administrator, all stated that residents should be kept clean and dry, that all staff share responsibility for addressing soiled clothing, and that leaving a resident in dirty clothes is a dignity issue. The facility’s Resident Rights policy states that residents have the right to be treated with respect and dignity.
Unsecured Nasal Spray Left at Bedside Contrary to Medication Storage Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were stored in locked compartments in accordance with state and federal requirements. Surveyors observed that a prescribed Fluticasone Propionate nasal spray, ordered as 50 mcg/ACT, one spray in each nostril once daily for allergies, was left on the bedside tray table of a resident. The resident, an elderly female with COPD, acute respiratory failure, anxiety disorder, and myopathy, had a BIMS score of 9 indicating moderate cognitive impairment, though she was able to make herself understood and understand others. Her care plan identified potential for impaired cognitive function and thought processes related to oxygenation status and COPD. During observation, the resident was seated in a chair with oxygen in use and the nasal spray was visible on her bedside tray. The resident stated that staff normally kept the medication locked up and she did not know why it remained on her table. Review of the facility’s policies showed that medications and biologicals were to be stored safely and securely, accessible only to licensed nursing personnel, pharmacy personnel, or staff authorized to administer medications. The facility’s self-administration policy required an interdisciplinary assessment and specific conditions, including lockable bedside storage, before residents could keep medications at bedside; the policy also required staff to report any unauthorized bedside medications. Interviews with staff confirmed that the facility did not currently allow residents to self-administer medications and that residents were not supposed to have medications in their rooms. A CMA acknowledged that she had given the resident her nasal spray, left the room, and later realized she had left the medication in the resident’s room, stating she was responsible for returning it to the medication cart. Other CMAs, an LVN, the ADON, the DON, and the administrator all stated that medications should not be left in resident rooms, that no residents were authorized for self-administration at that time, and that the nurse or medication aide in charge of the medication cart was responsible for ensuring medications were properly stored. This sequence of actions and inactions led to the medication being left unsecured at the resident’s bedside in violation of facility policy and regulatory requirements.
Improper Handling and Storage of Trash and Soiled Linens Compromises Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program related to the handling and storage of trash and soiled linens in one hall and two shower rooms. Surveyors observed dirty linens on the floor and a bag of trash in a clear bag behind the door in Shower #4. In Shower #2, dirty linens were also observed improperly stored. Staff interviews confirmed that dirty linens should not be on the floor and should be kept in designated linen barrels or bags, and that gloves should be worn when handling soiled linens. Surveyors further observed two bags of trash in clear bags placed on the floor in front of the shower room on Hall #2. A CNA was seen picking up these trash bags, placing them on top of a gray barrel, and rolling the barrel down the hall toward the outside. Multiple staff members, including CNAs, CMAs, housekeeping staff, the housekeeping supervisor, the ADON, DON, and the administrator, stated that trash should not be stored on the floor in hallways or behind shower doors, should be placed in yellow barrels, and should not be transported on top of gray barrels used for linens. They also stated that dirty linens should be bagged and placed in gray barrels or taken to the laundry, and that gloves should be worn when handling soiled linens. Record review of the facility’s infection control policy, "Fundamentals of Infection Control Precautions," indicated that hand hygiene is required after handling soiled linens and that gloving is used to prevent contamination when touching blood, body fluids, secretions, excretions, mucous membranes, and nonintact skin. The policy also stated that soiled linen should be handled, transported, and laundered in a manner that avoids transfer of microorganisms, including double-bagging soiled linen at the site where it is generated and transporting it by cart with appropriate PPE. The observed practices of leaving trash and soiled linens on floors, using clear trash bags, placing trash on top of gray barrels, and handling dirty linens without gloves were inconsistent with the facility’s stated infection control policies and procedures.
Improper Trash/Linen Handling and Unrepaired Broken Toilet in Shower Areas
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment on one resident hall and in two shower rooms. Surveyors observed dirty linens on the floor and a bag of trash in a clear bag behind the door in one shower room. Laundry staff stated that dirty linens should not be on the shower floor but in a linen barrel, and a housekeeper, who was not wearing gloves, picked up the dirty linens and placed them in the designated barrel, later acknowledging that gloves should have been worn when handling dirty linens. The ADON, a CNA, and other staff members consistently stated that dirty linens should be bagged and placed in gray barrels, trash should be placed in yellow barrels, and that linens and trash should not be stored on the floor. Surveyors also observed two bags of trash in clear bags on the floor in front of a shower room on one hall. A CNA was seen picking up the trash and placing it on a gray barrel to roll it down the hall. Multiple staff members, including a CMA, housekeeper, housekeeping supervisor, LVN, ADON, DON, and ADM, stated that trash should not be left on the floor in hallways or behind shower doors, should not be placed on top of gray linen barrels, and should instead be properly contained in yellow barrels and taken directly to the dumpster. One CNA admitted she was the person who placed the trash bags on the hallway floor and believed it was acceptable if the trash was bagged or combined with dirty linens for transport, which conflicted with the facility’s stated practices and staff expectations. In addition, surveyors observed that the toilet rim in one shower room was broken at the back, with exposed rigid porcelain edges. The broken toilet had been present for an extended period, as a housekeeper reported having submitted a maintenance request months earlier through a mobile QR application and stated that the toilet rim had been broken for a while. Nursing and administrative staff, including an LVN, ADON, DON, and ADM, reported they were not aware of the broken porcelain until it was brought to their attention during the survey. They each stated that any staff member who identified such damage would be responsible for reporting it immediately to maintenance or administration. The facility’s infection control policy required proper handling and transport of soiled linens with appropriate PPE and hygienic storage, and the resident rights policy required care in an environment that promotes quality of life, but the observed conditions in the hall and shower rooms did not align with these policies.
Widespread Abuse, Neglect, and Inadequate Supervision Identified
Penalty
Summary
The facility failed to protect multiple residents from abuse, neglect, and inadequate care, as evidenced by several documented incidents. One incident involved a nurse physically abusing a resident with Huntington's disease and severe cognitive impairment by lifting her from a wheelchair and throwing her onto a mattress on the floor, resulting in visible bruising and redness. Another incident involved a nurse verbally abusing a resident by yelling, cursing, and refusing pain medication, as corroborated by the resident, her family member, and other staff who witnessed the nurse's erratic and inappropriate behavior. Additionally, the facility did not prevent resident-to-resident physical abuse, as one resident with dementia and behavioral issues shoved another resident on two occasions, resulting in scratches and a fall. The care plans for these residents did not adequately address behavioral risks, and supervision was insufficient to prevent these altercations. The facility also failed to ensure proper positioning during tube feeding for a resident with severe cognitive and physical impairments, leading to aspiration pneumonia and hospitalization. Video evidence showed the resident left in an unsafe position for an extended period, with minimal staff intervention. Further deficiencies included inadequate staffing to provide necessary wound care, feeding assistance, and supervision during meals and on the secured unit. Multiple residents did not receive timely or appropriate care for pressure ulcers, feeding, and fall prevention. Staff interviews revealed ongoing concerns about insufficient staffing, lack of support from management, and inadequate training, which contributed to the inability to meet residents' needs and prevent harm.
Failure to Provide Adequate Supervision and Accident Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for multiple residents, resulting in both resident-to-resident altercations and unwitnessed falls. On two separate occasions, one resident physically pushed another, resulting in scratches and a fall, with both incidents occurring without staff witnessing the events. The care plan for the resident exhibiting physical behaviors did not address these behaviors, and the secured unit was inadequately supervised, as only one staff member was often present to oversee all residents. Staff interviews confirmed that the staffing was insufficient to provide proper supervision, with staff unable to monitor all residents while performing other care duties. Several residents experienced unwitnessed falls, some resulting in significant injuries such as fractures, lacerations, and emergency room visits. These incidents occurred in various locations, including hallways, dining rooms, and other residents' rooms, and were not observed by staff at the time. Care plans for some residents did not address fall risks, and interventions such as fall mats and supervision were inconsistently implemented or not effective due to lack of staff presence. Staff reported being overwhelmed and unable to complete all assigned tasks, including supervision and documentation, due to being the only staff member on the secured unit. Observations and interviews revealed that residents were frequently left unsupervised in common areas, including the dining room and hallways, sometimes for extended periods. Staff, including nurses and CNAs, reported that the nurse assigned to the secured unit often had to cover other areas, leaving only one person to supervise multiple residents with high care needs. The Director of Nursing and other staff acknowledged ongoing staffing shortages and the inability to provide adequate supervision, which contributed to the pattern of unwitnessed incidents and altercations among residents.
Failure to Provide Sufficient Nursing Staff and Care Interventions
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of its residents, as determined by resident assessments and individual care plans. This deficiency was observed through multiple incidents, including inadequate assistance with positioning during tube feeding, insufficient staff to provide wound care and documentation, and lack of adequate supervision and staffing on the secured unit, particularly during mealtimes. These failures were identified for a significant number of residents, with specific examples including a resident who was left leaning over the armrest of a Geri-chair for approximately 1 hour and 30 minutes during tube feeding, resulting in aspiration pneumonia, and several residents who did not receive required wound care treatments or documentation on multiple occasions. Resident records revealed that individuals with complex medical needs, such as those with Alzheimer's disease, severe malnutrition, pressure ulcers, and significant cognitive and physical impairments, were not consistently provided with the necessary care and supervision. For example, one resident with a gastrostomy tube and severe ADL dependency was not properly positioned during tube feeding, leading to a hospital transfer for aspiration. Other residents with stage 3 and stage 4 pressure ulcers had multiple days where wound care treatments were not documented as administered, despite physician orders and care plan interventions requiring daily or scheduled treatments. Additionally, the facility did not ensure that the secured unit was adequately staffed to prevent accidents and provide supervision during critical times such as mealtimes. The lack of sufficient staff led to missed care interventions, incomplete documentation, and increased risk for resident safety. The survey identified an Immediate Jeopardy situation due to these failures, which was later removed, but the facility remained out of compliance due to ongoing gaps in staff education and policy adherence.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to notify a resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status, specifically when the resident experienced multiple episodes of low blood pressure, low heart rate, and low blood pressure with increased heart rate over several days. Despite repeated abnormal vital signs and the holding of blood pressure medications due to these readings, there was no documented evidence that the physician was consistently notified as required by facility policy. The resident's care plan and medication orders clearly indicated the need for monitoring and reporting such changes, but this was not followed. The resident involved had a complex medical history, including dementia, gastrointestinal hemorrhage, iron deficiency anemia secondary to blood loss, hypertension, and acute embolism and thrombosis of deep veins. The resident was on anticoagulant and antihypertensive therapies, with specific parameters for holding medications based on vital signs. Over a period of several days, the resident's vital signs were repeatedly outside of these parameters, and medications were held accordingly. However, the process for escalating these findings to the physician was inconsistent, with staff interviews revealing confusion about notification responsibilities and a lack of documentation of physician contact in the clinical record. On one occasion, the resident was found to have critically low hemoglobin and hematocrit levels and was subsequently sent to the emergency room, where a gastrointestinal hemorrhage was diagnosed and a blood transfusion was administered. Interviews with staff and review of records indicated that the physician was not adequately informed of the ongoing abnormal vital signs and medication holds prior to this acute event. The facility's own policies required immediate physician notification for significant changes in status and for any held doses of regularly scheduled medication, but these procedures were not followed, leading to a deficiency finding by surveyors.
Failure to Ensure Proper Positioning During Enteral Feeding Leads to Aspiration
Penalty
Summary
A facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications associated with tube feeding. The resident, an elderly male with Alzheimer's disease, severe protein-calorie malnutrition, gastrostomy status, anorexia, and dysphagia, was dependent on staff for all activities of daily living and had significant cognitive and physical impairments. According to the care plan and physician orders, the resident required the head of the bed to be elevated to at least 30 degrees during and after tube feedings to prevent aspiration. On the day of the incident, the resident was observed via video leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes during a tube feeding. Despite a CNA briefly attempting to reposition him, the resident quickly returned to the slumped position and remained there, moaning and grunting, until a nurse later intervened and repositioned him with pillows. The CNA did not check on the resident again due to being the only staff member assigned to the hallway and feeling overwhelmed by staffing shortages. The nurse who later found the resident did not receive any report from the CNA about the improper positioning. Following the incident, the resident's family member, after reviewing the video footage, requested a chest x-ray due to concerns about possible aspiration. The resident was subsequently transferred to the hospital, where aspiration into the airway was confirmed. Interviews with staff revealed that both the CNA and the nurse recognized that improper positioning during tube feeding could result in aspiration, and both cited staffing concerns as a contributing factor to the failure to provide adequate care and monitoring.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for two residents who required such services, resulting in missed and delayed administration of scheduled pain medications, lack of pain assessments, and failure to offer alternative or non-pharmacological interventions as ordered. One resident, a female with diagnoses including fibromyalgia, chronic pain, and intact cognition, did not receive her scheduled doses of Oxycodone and Gabapentin on multiple occasions. Documentation showed that her pain assessments were not completed as required, and when doses were missed, the physician was not notified. Additionally, alternative PRN pain medications and non-pharmacological interventions, such as Tylenol and hot packs, were not offered per facility policy. The resident reported increased pain and agitation due to these lapses, and staff interviews confirmed confusion and lack of follow-through regarding medication administration and pain management responsibilities. Another resident, a male with severe cognitive impairment, dementia, and chronic pain, did not receive consistent pain assessments or PRN pain medications despite displaying nonverbal signs of pain such as grimacing, moaning, and pushing staff away during care. Although he was prescribed scheduled and PRN opioid medications, records indicated that PRN medications were not administered when he exhibited clear signs of discomfort during ADL care and wound treatments. Staff interviews revealed that pain assessments were not consistently documented, and PRN medications were not given prior to care activities known to cause pain, despite orders and care plan interventions specifying the need for such measures. The facility's failure to follow its own pain management policy, including timely administration of medications, documentation of pain assessments, and offering of alternative interventions, led to residents experiencing unmanaged pain and distress. Staff interviews and documentation review highlighted lapses in communication, inadequate handoff between shifts, and lack of adherence to professional standards of practice and individualized care plans. These deficiencies were identified by surveyors and resulted in an Immediate Jeopardy situation, though the report does not detail the corrective actions taken after the incident.
Failure to Implement and Maintain Infection Control Protocols During COVID-19 Outbreak
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program during a COVID-19 outbreak, as evidenced by multiple observations, interviews, and record reviews. Staff did not consistently follow infection control protocols, including the use of appropriate personal protective equipment (PPE) such as N-95 masks, face shields, or goggles when entering rooms of residents with confirmed COVID-19. PPE isolation carts were found to be missing required items, and staff were observed entering and exiting COVID-19 positive rooms without changing masks or performing hand hygiene due to lack of access to hand sanitizer. Additionally, signage indicating airborne isolation precautions was missing from the doors of several residents on isolation, and there was no signage at the facility entrance to alert staff and visitors to the outbreak status. Several residents with confirmed or suspected COVID-19, including those with severe cognitive impairment and complex medical histories, were not properly isolated or monitored according to facility protocols. For example, residents with active COVID-19 infections did not have appropriate isolation signage outside their rooms, and staff were observed providing care without the required PPE. In some cases, staff continued to wear the same masks after leaving COVID-19 positive rooms and provided care to other residents without changing masks or performing hand hygiene. Staff also reported not having access to necessary PPE, such as face shields or goggles, and hand sanitizer dispensers had been removed from the walls, further impeding proper infection control practices. The facility's leadership, including the Administrator, DON, and ADON, demonstrated a lack of awareness and oversight regarding the infection control protocols and the status of PPE and signage. Interviews revealed that the ADON was new and had not fully assumed responsibility for the infection control program, while the DON and Administrator were unaware of the deficiencies in PPE availability and signage. Additionally, residents who developed new signs and symptoms of COVID-19 were not promptly tested, contrary to facility policy. These failures were directly observed and confirmed through staff interviews, highlighting significant lapses in the facility's infection prevention and control measures during the outbreak.
Failure to Treat Resident with Dignity and Respect During Medication Dispute
Penalty
Summary
A deficiency occurred when a nurse failed to treat a resident with respect and dignity during an interaction regarding missed pain medications. The resident, who had diagnoses including fibromyalgia, low back pain, major depressive disorder, and anxiety, was cognitively intact and able to communicate her needs. On the day in question, the resident did not receive her scheduled pain medications at the expected time and reported being in pain. She made multiple calls to the front desk requesting her medications, but the nurse did not arrive until several hours later. When the nurse finally entered the resident's room, both the resident and the nurse raised their voices during the exchange. The resident reported that the nurse was condescending, clapped her hands at her, and acted in a superior manner. A CNA who witnessed the incident stated that the nurse spoke forcefully and with an attitude, describing the interaction as disrespectful and not conducive to resolving the situation. The CNA also noted that the nurse's tone was inappropriate and that she had never seen the resident so upset before. Interviews with facility leadership confirmed that staff are expected to communicate with residents in a polite and dignified manner. The DON and administrator acknowledged that speaking to a resident in a disrespectful way constitutes a violation of resident rights and dignity. The facility's policy also states that residents have the right to a dignified existence and must be treated with respect at all times.
Failure to Prevent Misappropriation of Resident's Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of property, specifically regarding the administration and documentation of the resident's prescribed Oxycodone. The resident, who had diagnoses including fibromyalgia and low back pain, was on a scheduled opioid regimen and was cognitively intact, independently managing aspects of her care and regularly counting her medications. On the date in question, records showed that six doses of Oxycodone were documented as administered, despite only five being scheduled. Discrepancies were noted between the individual control drug record and the electronic medication administration record (eMAR), with the control record reflecting an extra administration that was not corroborated by the eMAR or the resident's own account. Multiple staff members, including medication aides and nurses, identified and reported the irregularity in the narcotic count and documentation. The nurse responsible for the extra entry could not provide a clear explanation, alternately stating she may have given an extra dose or simply documented the wrong time. The resident denied receiving an extra dose and consistently counted her pills before taking them. The incident was reported up the chain of command, and interviews with staff indicated concerns about the nurse's behavior and the possibility of drug diversion, though the nurse was not immediately suspended for this incident. The facility's own policies defined misappropriation of resident property as the wrongful use of a resident's belongings, including medications. The documentation and interviews confirmed that a dose of the resident's Oxycodone was unaccounted for and could not be reconciled through resident or staff accounts, nor through medication records. The failure to ensure accurate administration and documentation of controlled substances resulted in the misappropriation of the resident's medication.
Failure to Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation of property were thoroughly investigated and that residents were protected from further potential harm. In one instance, a nurse was reported to have documented an extra administration of a resident's oxycodone, raising concerns of possible drug diversion. Despite the resident denying receipt of an extra dose and staff reporting the incident to facility leadership, there was no evidence of a comprehensive investigation into the alleged misappropriation. The nurse in question continued to work with the resident after the incident until being suspended several days later, and there was no documentation of a thorough inquiry or protective measures taken immediately following the allegation. Another resident experienced an alleged incident of neglect when the same nurse failed to administer requested pain medication. The resident and her family reported that the nurse refused to provide the medication, acted in a verbally aggressive manner, and displayed erratic behavior. Documentation revealed that the pain medication was not signed out as administered, and there was no evidence that a pain assessment was completed or that the medication administration record was reviewed to verify the omission. The investigation into this incident was incomplete, lacking attempts to determine the reason for the alleged omission or to fully assess the resident's condition at the time. Interviews with facility staff, including the DON and Administrator, revealed confusion and lack of clarity regarding responsibility for conducting thorough investigations into these allegations. The facility's own policy required comprehensive investigations of all abuse, neglect, and misappropriation allegations, but this was not followed in these cases. The lack of thorough investigation and immediate protective actions left residents at risk for continued abuse, neglect, and misappropriation.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision measures were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Allow Use of Motorized Wheelchair for Resident with Mobility Needs
Penalty
Summary
The facility failed to ensure that a resident was allowed to use his personal motorized wheelchair during his stay, despite his prior use of such a device and his medical need for independent mobility. The resident, who had spastic quadriplegic cerebral palsy and chronic kidney disease, was admitted to the facility and had a BIMS score indicating intact cognition. Upon admission, he informed staff that his motorized wheelchair would be arriving, but the facility did not permit him to use it, instead providing a manual wheelchair that he was unable to propel independently due to his physical limitations. Interviews with facility staff revealed that there was a longstanding practice of not allowing motorized wheelchairs, originating from a previous administrator's decision after an incident involving another resident. However, current staff, including the ADON and the Administrator, indicated that the expectation was to allow motorized wheelchairs if the resident was assessed by therapy and found to be safe. Despite this, the resident was not given the opportunity for such an assessment and was denied the use of his motorized wheelchair throughout his stay. Facility policy stated that residents have the right to retain and use personal possessions, including motorized wheelchairs, unless doing so would endanger the health or safety of others. The policy also required an assessment for safe use of electric wheelchairs. In this case, the facility did not follow its own policy or provide reasonable accommodation for the resident's needs and preferences, resulting in the resident's loss of independence and reliance on staff for mobility.
Improper Storage of Oxygen Cylinder in Resident Room
Penalty
Summary
A deficiency was identified when an oxygen cylinder was found stored upright on the floor in a resident's room, rather than in a caddy or secured storage area as required by facility policy. The resident, a male with diagnoses including pleural effusion, heart failure, and end stage renal disease, was observed lying in bed while the unsecured oxygen tank remained on the floor. The resident was unsure how long the tank had been present in this manner. Multiple observations confirmed the tank's improper storage, and staff interviews revealed that the tank should have been stored in a caddy or secure area to prevent it from being knocked over. Staff members, including an LVN, the Maintenance Supervisor, the ADON, and the Administrator, all acknowledged during interviews that oxygen tanks should not be left free-standing and must be properly secured to prevent accidents. The facility's policy on the safe handling of compressed gases specifically states that tanks must be stored in a cylinder cart or securely chained in a storage area, and never left free-standing. The failure to follow this policy resulted in the cited deficiency.
Non-Functional Call Light Leaves Dependent Resident Unable to Summon Assistance
Penalty
Summary
A deficiency was identified when a resident's call light was found to be non-functional, preventing the resident from being able to summon staff assistance. The issue was discovered during an observation and interview, where the resident requested help and the call light did not activate when pressed. The resident's roommate confirmed that the call light had not been working for approximately two weeks, and she had been using her own call light to request help on behalf of the affected resident. Staff members, including a CNA, verified that the call light was not working and acknowledged the risk to the resident, noting that maintenance had not been notified of the issue prior to the surveyor's discovery. The resident affected by the deficiency had significant medical needs, including diagnoses of dementia, heart failure, and major depressive disorder. She was severely cognitively impaired, completely dependent on staff for all activities of daily living, and always incontinent of bowel and bladder. Her care plan required that adaptive equipment, such as a functional call light, be provided and maintained. Despite these needs, the call light remained non-functional for an extended period, and there was no documentation or maintenance request indicating that the issue had been previously reported or addressed. Interviews with facility staff, including the Maintenance Supervisor, ADON, and Administrator, revealed that routine checks of call lights were conducted, but the specific non-functioning call light in the resident's room had not been identified or reported through the facility's maintenance request system. The facility's records showed that the call lights in the affected room were only checked on the day of the survey, with no prior checks documented for the preceding period.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident who resided on a secured unit. The resident, who had a history of wandering and severe cognitive impairment, was able to leave the facility unsupervised. The resident was found at a local hospital emergency room after being taken there by local police. The facility was unaware of the resident's absence for approximately four hours until staff went to retrieve him for his evening meal. The resident had a care plan indicating a risk for wandering and elopement, requiring a secured unit and close supervision. Despite these measures, the resident managed to elope from a window in an empty room on the secure unit. The resident had previously demonstrated behaviors such as pacing, rummaging through other residents' belongings, and attempting to leave the facility. Staff had noted these behaviors in progress notes, but the interventions in place were insufficient to prevent the elopement. Interviews with staff revealed that the resident had been seen after lunch but was not accounted for until supper time. The resident had used a toilet tank lid to break a window and exit the facility. Staff were not aware of the resident's ability to disable window alarms and remove thumb locks, which contributed to the elopement. The facility's lack of a specific policy on making rounds and the failure to monitor the resident closely enough allowed the incident to occur.
Resident Restraint Violation in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints, which is a violation of resident rights. A certified nursing assistant (CNA) admitted to restraining a resident on multiple occasions, including swaddling the resident with a blanket and tying the resident's legs to the bed with leggings. This restraint was applied from early morning until later that morning, during which time the resident was unable to move freely. The resident involved had a complex medical history, including Huntington's Disease, schizoaffective disorder, and anxiety disorder, which contributed to her involuntary movements and agitation. The resident was known to have a history of falls and required supervision for all activities of daily living. Despite these needs, the CNA took it upon herself to restrain the resident without proper authorization or medical necessity, citing concerns for the resident's safety as justification. The incident was discovered when another CNA attempted to assist the resident and found her tied to the bed. The facility's administration was notified, and an investigation was initiated. Interviews with staff revealed that the CNA responsible for the restraint had previously received training on abuse, neglect, and the facility's restraint-free policy, yet chose to disregard these protocols. The facility's failure to prevent this incident placed the resident at risk of harm and demonstrated a lack of adherence to established resident rights and safety procedures.
Failure to Prevent Accident Hazards and Ensure Adequate Supervision
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by two separate incidents involving residents. In the first incident, a resident with severe cognitive impairment and a history of wandering was found with an unattended spray bottle of cleaner in the dining room. The resident had the nozzle in one hand and the bottle in the other, and there was a lemon scent detected on her breath, suggesting possible ingestion. The cleaner was not an approved facility product and was left unattended by a staff member, contrary to facility policy requiring chemicals to be stored in a locked area. In the second incident, a resident who required dialysis and used a wheelchair was not properly secured during transportation in the facility's van. The resident's wheelchair was not adequately strapped, leading to the wheelchair tipping backward during transit, resulting in two abrasions to the resident's scalp. The transport CNA responsible for securing the resident had not been trained on how to properly secure and transport residents, which contributed to the incident. The CNA moved the resident after the fall without conducting a proper assessment, which was against protocol. Both incidents highlight significant lapses in supervision and adherence to safety protocols, placing residents at risk of harm. The facility's failure to ensure proper training and adherence to safety procedures for handling chemicals and securing residents during transport were key factors leading to these deficiencies.
Failure in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications underwent gradual dose reductions and behavioral interventions, as required by regulations. Specifically, the facility did not adequately assess the necessity of these medications for treating specific conditions, nor did it limit PRN orders for psychotropic drugs to 14 days without proper documentation from the prescribing practitioner. This deficiency was observed in four residents, including a resident who experienced lethargy, increased falls, incontinence, unusual behavioral symptoms, and weight loss due to the side effects of Lorazepam and Risperidone. The facility did not notify the physician of a significant weight loss in one resident, nor did it accurately report the resident's behaviors to the physician, leading to inappropriate medication adjustments. The resident was reported to be aggressive, which was not consistent with the observed behaviors of wandering. Additionally, the facility failed to ensure that the resident had appropriate diagnoses for the use of Trazodone and Lorazepam, contributing to the misuse of these medications. Furthermore, the facility did not limit the use of PRN Lorazepam for other residents to 14 days, nor did it provide the necessary rationale for extended use. This lack of monitoring and evaluation of psychotropic medication use placed residents at risk for adverse side effects and decreased quality of life. The facility's failure to implement proper medication management and monitoring protocols resulted in potential harm to the residents.
Inaccurate PASRR Screenings for Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Pre-Admission Screening and Resident Review (PASRR) Level I assessments for four residents, which resulted in the omission of mental illness diagnoses. Resident #49, who was re-admitted with a diagnosis of Post Traumatic Stress Disorder (PTSD), had a PASRR Level I screening that incorrectly indicated no mental illness. Similarly, Resident #15, admitted with schizoaffective disorder and major depressive disorder, also had a PASRR Level I screening that failed to reflect these mental health conditions. Resident #52, who was readmitted with a diagnosis of major depressive disorder, had a PASRR Level I screening that did not acknowledge her mental illness. Additionally, Resident #16, who had a history of major depressive disorder and was readmitted with a diagnosis of depression, had a PASRR Level I screening that inaccurately marked no mental illness. These inaccuracies in the PASRR screenings could potentially prevent residents from receiving necessary assessments, individualized care, or specialized services. Interviews with facility staff, including MDS nurses and social workers, revealed a lack of awareness and understanding regarding the need to update PASRR screenings when residents are admitted or re-admitted with mental health diagnoses. The facility's policy requires that PASRR evaluations be completed within specific timeframes and that any positive findings be communicated to the interdisciplinary team. However, the failure to accurately complete these screenings suggests a breakdown in the facility's processes for ensuring compliance with PASRR requirements.
Lack of Meaningful Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs of residents in the memory care unit, as observed during a survey conducted from September 30 to October 1, 2024. Observations revealed that the dining and sitting areas, as well as the hallways, lacked dementia-focused activities, with a television playing in the background that did not engage the residents. The activity schedule for October 2024 listed various activities, but these were not observed being implemented in the memory care unit. Interviews with staff, including CNAs and an LVN, indicated that the activity director was responsible for conducting activities but was not consistently present in the memory care unit. Staff reported that the activity director visited the unit infrequently, primarily to deliver snacks, and that the aides were left to occupy the residents. The staff expressed uncertainty about the specific interests of some residents and suggested that the lack of activities might contribute to falls and incidents among the residents. The Director of Nursing and the Administrator acknowledged the importance of activities for dementia residents and noted that the activity director had been absent due to personal reasons. The Administrator mentioned that there was an activity closet available for use by the aides, but it was not being utilized effectively. The absence of a specific activity calendar for the memory care unit and the lack of meaningful activities were identified as contributing factors to the deficiency.
Inadequate Hydration for Residents
Penalty
Summary
The facility failed to ensure adequate hydration for three residents, leading to potential health risks. Resident #36, a male with multiple sclerosis, depression, and hypertension, reported having a dry mouth due to insufficient fluid intake. His care plan indicated a potential for nutritional problems, yet during an observation, it was noted that his water was from the previous evening, and he expressed a preference for ice in his water. Resident #42, a male with cerebral infarction, peripheral vascular disease, diabetes, depression, and vascular dementia, also experienced inadequate hydration. Despite being able to communicate, he had to request ice and water, and his cup was observed to be out of reach and without ice on multiple occasions. His quarterly MDS assessment indicated severe cognitive impairment, which may have contributed to his inability to ensure his hydration needs were met independently. Resident #61, diagnosed with Alzheimer's disease, atrial fibrillation, subdural hemorrhage, diabetes, and depression, was similarly affected. His care plan included interventions to encourage fluid intake and ensure fluids were within reach. However, observations revealed that his cup was often empty or out of reach, and his lab results showed elevated BUN levels, suggesting possible dehydration. Interviews with staff highlighted inconsistencies in the facility's hydration practices, with some staff expressing dissatisfaction with the current system and acknowledging the potential health risks of inadequate fluid intake.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of several residents, resulting in missed medication doses and improper medication administration. Specifically, Resident #18 did not receive Niacin, Ativan, and Nicotine Patch on multiple occasions due to unavailability. The records indicated that the medications were either on order or awaiting delivery, and the emergency kit did not have the necessary doses. This lack of availability was acknowledged by the medication aides and nurses, who reported the issues to the nursing staff. Resident #23's Aspirin EC, which was not supposed to be crushed, was administered in a crushed form, potentially altering its effectiveness. The medication aide responsible for administering the medication was unaware of the order's instruction not to crush the medication. This oversight was observed during a medication pass, where the medication was given with a custard substance. Resident #34 and Resident #68 also experienced issues with medication availability. Resident #34's Lorazepam was not available for several days, and the emergency kit was empty. Similarly, Resident #68's Lomotil was not delivered in a timely manner, resulting in missed doses. Interviews with staff revealed that there were communication issues with the pharmacy regarding medication delivery, and the facility's emergency kit was not adequately stocked to address these shortages.
High Medication Error Rate in Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 61.76% involving four residents. The errors included late administration of medications, incorrect infusion rates, and failure to administer prescribed medications. These errors were observed during medication administration for residents with complex medical conditions, including Alzheimer's disease, anxiety, depression, epilepsy, and chronic pain. One resident received multiple medications, including Buspirone, Lorazepam, and Tramadol, significantly later than the prescribed time. Another resident's medications, such as Divalproex and Sertraline, were also administered outside the facility's liberalized policy time. Additionally, a resident's IV antibiotic was administered at an incorrect rate, potentially leading to adverse effects. These discrepancies were attributed to staff being behind schedule and a lack of assistance from other nursing staff. Interviews with staff revealed a misunderstanding of medication administration times and a lack of adherence to physician orders. The Director of Nursing and other staff acknowledged the importance of timely medication administration and the potential risks of late or incorrect dosing. The facility's liberalized medication policy was not consistently followed, contributing to the high error rate.
Failure to Adhere to Medication Parameters
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors related to the administration of losartan, a blood pressure medication. Resident #23 received losartan on multiple occasions when her blood pressure and heart rate were outside the ordered parameters. Specifically, the medication was administered on dates when her heart rate was below the threshold set by the physician's order. Similarly, Resident #34 was given losartan when her blood pressure readings were below the specified parameters on several occasions. Interviews with facility staff revealed a lack of understanding and adherence to medication administration protocols. Medication Aide (MA) O admitted to administering the medication despite the residents' vital signs being outside the prescribed limits, based on instructions from the nurse. The Licensed Vocational Nurse (LVN) E confirmed that the facility had not instructed nurses to monitor MAs to ensure compliance with medication hold parameters. The Director of Nursing (DON) and the Administrator acknowledged the expectation that medications should be held when vital signs are not within the prescribed range. The facility's Medication Administration Procedures policy outlines the importance of adhering to the ten rights of medication administration, including the right assessment and evaluation. However, the failure to follow these procedures resulted in the administration of losartan to residents when their vital signs indicated that the medication should have been withheld, potentially placing them at risk for adverse effects.
Failure to Provide Baseline Care Plan to Resident's Responsible Party
Penalty
Summary
The facility failed to ensure that a baseline care plan, which included instructions for effective and person-centered care, was completed and provided to the responsible party (RP) of a resident within 48 hours of admission. The resident, a female with severe cognitive impairment and multiple diagnoses including dementia with psychotic disturbance and paranoid schizophrenia, was admitted to the facility. Although the resident received a copy of the baseline care plan, her RP did not, which could lead to a lack of understanding of the care being provided. Interviews with facility staff, including an LVN, MDS Nurse, DON, and ADM, revealed that the responsibility for providing the baseline care plan to the RP was not consistently executed. Staff acknowledged the importance of providing the RP with a copy to ensure they were informed about the resident's care and to gather additional information that could aid in the resident's care. Despite the facility's policy to provide a summary of the baseline care plan to the resident and their representative, this was not done for the RP of the resident in question.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. Resident #62's care plan did not include her prescribed psychotropic medication, Lorazepam, which was ordered by the physician but inconsistently administered. Interviews with the ADON, DON, and Administrator revealed that they expected a care plan for psychotropic medications to be in place to prevent unfamiliar staff from missing necessary interventions. Resident #34's care plan did not address her behavioral symptoms, including urinating on her and other residents' property, despite these behaviors being documented in progress notes. The care plan also failed to reflect other behavioral symptoms coded on the MDS. Interviews with staff, including LVN E, CNA D, and MDS Nurse M, indicated that these behaviors should have been care planned to ensure proper interventions and goals were established. Resident #53's care plan lacked documentation of her limited range of motion and her activity preference for listening to music. Observations noted her lower extremities appeared bent without voluntary movement, and she had a radio playing music in her room. Interviews with staff, including LVN E, CNA D, and the DON, highlighted the importance of care planning these aspects to ensure the resident's needs and preferences were met. The facility's policy stated that comprehensive care plans should include measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Provide Scheduled Baths for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for three residents, resulting in missed scheduled baths. Resident #25, a male with cerebral palsy and heart failure, required substantial assistance with bathing. His care plan indicated he was totally dependent on staff for bathing, scheduled for Tuesdays, Thursdays, and Saturdays. However, documentation showed he only received a bed bath on a few occasions in August and September, with many scheduled days lacking any documentation. Interviews with the resident and staff confirmed the baths were likely missed due to staff turnover and lack of documentation. Resident #42, a male with severe cognitive impairment and multiple health conditions, required supervision or touching assistance with bathing. His care plan indicated he was scheduled for baths on the evening shift, but documentation showed he had not received a bath for several weeks. Interviews revealed that the resident was unsure of when he last received a shower, and staff acknowledged that documentation was missing, indicating the baths were not performed as scheduled. Resident #61, a male with Alzheimer's disease and severe cognitive impairment, required set-up or clean-up assistance with bathing. His care plan indicated he was scheduled for baths three times a week, but documentation showed he received only a few baths in August and September. Interviews with the resident's representative and staff revealed concerns about the resident's hygiene and lack of documentation, suggesting the baths were not provided as required. Staff turnover and inadequate documentation were cited as contributing factors to the missed baths.
Failure to Replace Damaged Oxygen Filter
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not replacing a damaged oxygen filter on the resident's oxygen concentrator. The resident, a female with a history of Chronic Obstructive Pulmonary Disease (COPD), Chronic Systolic Heart Failure, and Hyperlipidemia, was observed to have an oxygen concentrator with a filter that was 90% missing. This observation was made during a survey, and it was noted that the absence of a proper filter could lead to respiratory infections. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility had policies in place requiring nurses to ensure that oxygen concentrators have clean and functioning filters. The ADM mentioned that the maintenance supervisor was responsible for daily checks of the oxygen concentrators. However, the failure to replace the damaged filter indicated a lapse in following these procedures, potentially exposing the resident to dust and bacteria.
Failure to Maintain Sanitary Conditions in Residents' Personal Refrigerators
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in the personal refrigerators of two residents. For one resident, expired protein drinks were found in their personal refrigerator. This resident, who had severe cognitive impairment and required substantial assistance with activities of daily living (ADLs), was unaware of the expiration dates on the items in their refrigerator. Interviews with the Director of Nursing (DON) and the Administrator revealed that housekeeping and Certified Nursing Assistants (CNAs) were responsible for ensuring that residents' personal refrigerators were clean and free of expired food. However, this responsibility was not adequately fulfilled, placing the resident at risk of harm from consuming expired products. In the case of the second resident, their personal refrigerator was observed to be unclean, containing a brown and black substance with dead gnats. This resident, who had intact cognition and required supervision with ADLs, was aware of the unsanitary condition of their refrigerator but continued to consume food from it. Interviews with various staff members, including CNAs, housekeeping, and nursing staff, indicated confusion and lack of clarity regarding who was responsible for cleaning the residents' refrigerators. The DON and Administrator acknowledged that the facility's policy required family members to ensure cleanliness, but in their absence, facility staff were responsible. The facility's policy on personal refrigerators, dated 2012, stated that residents or their responsible parties were accountable for the care and maintenance of personal refrigerators. However, the policy also allowed for housekeeping to assist by inspecting refrigerators weekly and removing outdated food items. Despite this policy, the facility failed to implement it effectively, resulting in unsanitary conditions and expired food in residents' personal refrigerators, which could pose a risk to their health.
Improper PPE Use in COVID-19 Positive Resident's Room
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by a medical assistant (MA S) when entering and exiting the room of a COVID-19 positive resident. The resident, an elderly female with multiple diagnoses including dementia, paroxysmal atrial fibrillation, type II diabetes, and COVID-19, was placed on isolation precautions. Despite the presence of signage indicating the need for full PPE, MA S entered the resident's room wearing only a surgical mask, contrary to the requirement for an N95 mask, gown, gloves, and face shield. The deficiency was further highlighted by the failure of MA S to change her mask after leaving the COVID-19 positive resident's room, which is a critical step in preventing cross-contamination and the spread of infection. Interviews with other staff members, including a CNA, RN, MDS nurse, ADON, and DON, revealed a general understanding of the PPE requirements for entering 'warm' and 'hot' zones, yet MA S did not adhere to these protocols. The staff acknowledged that full PPE should be worn in such zones and that PPE should be disposed of in the resident's room, followed by hand hygiene. The facility's policies and signage provided clear instructions on the sequence for donning and removing PPE, emphasizing the importance of using N95 masks or higher-level respirators in the care of COVID-19 positive patients. Despite these guidelines, the incident with MA S demonstrated a lapse in adherence to infection control practices, which could potentially lead to the spread of communicable diseases within the facility.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of an investigation into an alleged abuse incident between two residents to the state survey agency within the required 5 working days. The incident involved a resident reporting being slapped by another resident. Both residents were assessed, and no marks or injuries were found. The facility's investigation concluded that the allegation was unfounded. However, the administrator did not submit the investigation report to the state survey agency as required by state law. The administrator acknowledged during interviews that she did not send the provider investigation report to the state within the required timeframe. She admitted to being solely responsible for the submission and mentioned that she had forgotten to send it. The facility's policy on abuse and neglect requires that a written report be sent to the state no later than the fifth working day after the initial report, but this was not adhered to in this case.
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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