Woodway Nursing & Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 2808 Stoneybrook Drive, Houston, Texas 77063
- CMS Provider Number
- 675078
- Inspections on file
- 33
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 30 (10 serious)
Citation history
Health deficiencies cited at Woodway Nursing & Rehab during CMS and state inspections, most recent first.
A resident with severe malnutrition, multiple comorbidities, and several pressure ulcers had physician orders for daily day-shift wound care to multiple sites, including both hips, coccyx, shoulder, foot, and a DTPI on a toe. The TAR showed wound care documented on only one day within a critical multi-day period, with no entries for the following three days, and staff interviews revealed inconsistent, uncorroborated claims that treatments were performed but not documented. When wound care was finally provided again, nurses and CNAs observed unchanged dressings dated from several days prior, foul odor, and significant drainage from the left hip wound. On assessment, the WCD found the left hip ulcer to be unstageable, very smelly, and infected with purulent drainage and increased size, and stated that providing wound care on the missed days could have helped prevent the decline of that wound, while hospice staff characterized the lack of treatment as neglect and noted that infections were avoidable.
A resident with dementia, stroke, COPD, and hospice services was documented in the medical record and by hospice as Full Code, but this status was not reflected in the MDS, care plan, or the code status binder, which incorrectly listed the resident as DNR. On one evening, a CNA found the resident unresponsive and not breathing and notified an LVN, who assessed the resident but did not document vital signs and did not initiate CPR, relying instead on the incorrect DNR status in the binder. The LVN reported the death to the NP and DON, misidentified which resident had died, and hospice was not notified at the time, resulting in no basic life support being provided despite the resident’s Full Code orders and facility policy requiring CPR in the absence of obvious signs of clinical death.
The facility failed to maintain confidentiality of electronic medical records and to provide requested records to a resident’s representative. A CNA left a wall-mounted computer logged into the EMR system and unattended on a hall, and the DON later confirmed that from the home screen staff could access resident records without an additional password. Separately, an entity representing a deceased resident’s RP sent multiple certified and first-class mail requests for the resident’s complete medical record, with proper authorization and identification attached, to the facility’s leadership and parent company, but facility staff, including the SW, MR staff, and business office managers, reported no knowledge of any such requests. The Administrator stated that mail addressed to the prior company would not be signed for and would be returned, and that the facility did not receive any mail related to this resident, despite postal documentation and state law requiring provision of medical records within a defined period after receipt of a written, authorized request.
A resident with multiple complex medical conditions was readmitted from the hospital and did not receive several scheduled doses of IV antibiotics due to incomplete communication and missing clinical records. The admitting nurse did not obtain a full report or clarify missing orders, resulting in a delay in starting the prescribed medications. The error was later identified after review of updated records and staff interviews.
A resident was readmitted to the facility and placed in a room that had not been cleaned or prepared according to policy. The room contained used medical supplies, debris, and unclean linens, and staff interviews confirmed that proper cleaning procedures were not followed due to communication gaps between nursing and housekeeping. The facility's policy requires rooms to be cleaned and disinfected before admission, but this was not done in this case.
A CNA did not wear a disposable gown while providing direct care to a resident on Enhanced Barrier Precautions, despite clear signage and available PPE. The resident had multiple complex medical conditions, including a gastrostomy tube and end stage renal disease. The facility's infection control policy required staff to use gloves and gowns for such care, but this protocol was not followed.
Two residents with histories of aggression and inappropriate behaviors were placed together as roommates, despite known incompatibility, resulting in a physical altercation and injury. The facility failed to address or document sexually inappropriate behavior, did not update care plans to reflect ongoing risks, and did not consistently implement or document interventions. Staff were not always aware of or did not follow up on incidents, and the facility's investigation was incomplete, lacking required notifications and staff statements.
Two residents with cognitive impairment and behavioral symptoms, including restlessness and pulling on their G-tubes, experienced repeated dislodgement of their feeding tubes without adequate preventive interventions such as abdominal binders. These incidents led to hospitalizations and injury, and the residents' care plans did not address their risk behaviors or include necessary interventions prior to the events. Staff were aware of the behaviors but did not implement or document appropriate measures to prevent tube dislodgement.
The facility failed to provide appropriate treatment and services for three residents with mental disorders or psychosocial adjustment difficulties, resulting in repeated incidents of aggression, suicide attempts, and disruptive behaviors. Staff did not implement behavior monitoring or targeted interventions, and care plans did not address the residents' risks for self-harm or aggression, leading to emergency interventions and placing residents at risk.
Live gnats were observed in a shower room and on a towel placed on a resident, with additional gnats circling the resident, while a cockroach was seen and killed at a nursing station. Staff acknowledged the pest issue, and records showed recent pest control treatment was limited to the kitchen, not the affected areas, indicating a lapse in the facility's pest control program.
Two residents with dementia and histories of aggression were involved in an altercation resulting in one being hit in the eye. The facility did not document notifications to the Ombudsman or law enforcement, nor did it include staff witness statements in the investigation. Care plans did not fully address aggressive behaviors or the incident, and required investigation procedures were not followed according to facility policy.
Surveyors found that the facility failed to maintain a clean and homelike environment, with many residents left on bare mattresses due to a lack of clean linens, insufficient hot water for bathing, and missing privacy curtains. Residents with complex medical needs reported feeling unclean, cold, and neglected, while staff described ongoing shortages of essential supplies and difficulties providing proper care. Environmental issues included broken laundry equipment, unreliable return of personal clothing, and unsanitary conditions due to uncollected trash.
Multiple residents were left without clean linens, towels, or adequate care supplies, resulting in individuals lying on bare mattresses, feeling cold, unclean, and neglected. Staff reported ongoing shortages of essential items, broken laundry equipment, and unreliable processes for returning personal clothing. The lack of hot water in rooms and showers further prevented proper hygiene, and the cumulative effect of these failures led to widespread neglect and emotional distress among residents.
A resident with a history of stroke and contractures did not receive a required hand roll for his contracted left hand as outlined in his care plan. Staff were unaware of who was responsible for ensuring the intervention, and the care plan lacked documentation for the hand contracture and nail care. The resident reported the hand roll had been lost and not replaced, and staff interviews revealed confusion about care plan implementation.
A resident with significant physical impairments sustained a finger injury during staff-assisted dressing, resulting in pain and bleeding. The injury was not reported, documented, or addressed in the care plan, and no physician orders or incident reports were found. The resident's wound was discovered with an undated dressing, and facility policy for accident reporting and follow-up was not followed.
A resident with a history of stroke and significant upper extremity impairment was not accurately assessed or documented in the MDS or care plan. The resident's left hand contracture was observed but not included in the assessment or care planning, and staff interviews confirmed the omission. Facility policy requires comprehensive assessment and care planning, but this process was not followed for the resident's upper extremity impairment.
A resident with significant physical impairments and dependence on staff for personal hygiene was found with long, dirty fingernails, one of which was injured and bandaged after being caught on clothing during care. Staff interviews revealed a lack of awareness and responsibility for nail care, and records showed no documentation or physician orders for nail care, nor was the injury addressed in the care plan. Facility policies for documentation and monitoring were not followed, resulting in unmet hygiene needs.
Multiple areas of the facility were found to be unsafe and unsanitary, including loose toilets and sinks in resident bathrooms, a damaged window held together with duct tape, and an overflowing outdoor trash area with debris and rodent activity. Additionally, several rooms and common areas lacked adequate hot water due to a delayed repair of a broken circulation pump, impacting hygiene and comfort for residents and staff.
A resident with multiple medical conditions sustained an injury to his left middle finger, which was not documented in his medical record. The injury, which occurred during assistance with clothing removal, was observed by surveyors, but there was no incident report, skin assessment, or care plan update. Nursing staff and administration were unaware of the injury, and facility policies requiring documentation and reporting of such events were not followed.
A resident with cognitive impairments and physical disabilities was burned by hot coffee in an LTC facility. The coffee was served at an unsafe temperature without proper supervision, and the facility failed to maintain a temperature log. The dietary staff involved was not adequately trained, and the facility's policy on hot liquids was not effectively implemented, leading to the resident's injury.
Two residents in an LTC facility experienced falls due to inadequate supervision and failure to implement safety measures. One resident, with severe cognitive impairment, did not have a fall mat as required by her care plan, while another resident was left unattended in a wheelchair for over three hours, resulting in a fall. Staff interviews revealed a lack of communication and awareness regarding the residents' fall risks and necessary interventions.
A resident with diabetes and severe cognitive impairment did not receive timely podiatry care, resulting in overgrown toenails and potential infection risk. Despite a podiatrist consult being noted, the resident's toenails were not trimmed since admission, and staff failed to coordinate necessary services. Observations showed the resident's toenails were extended and curled, with dry skin on his feet, highlighting a lack of communication and follow-through among facility staff.
Failure to Provide Ordered Daily Wound Care Resulting in Infected Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered daily wound care to a resident with multiple pressure ulcers, resulting in an infected left hip wound. The resident, a 75-year-old man, was admitted with severe protein-calorie malnutrition, metabolic encephalopathy, peripheral vascular disease, and existing pressure ulcers, including sacral and right heel ulcers and osteomyelitis of the right ankle and foot. On readmission from the hospital, he had multiple pressure injuries: unstageable pressure ulcers on both hips, a stage 4 ulcer on the left posterior shoulder, a stage 3 coccyx ulcer, an unstageable ulcer on the left medial lateral foot, and a DTPI on the left 5th toe. Physician orders dated 2/11/26 required that each wound be treated every day shift with normal saline, pat dry, and application of Santyl, calcium alginate, and border foam dressings, and that the DTPI on the 5th toe be treated with betadine and iota every day shift. Despite these orders, the treatment administration record (TAR) showed wound care documented only on 2/22/26, with all wound care documentation left blank for 2/23/26, 2/24/26, and 2/25/26. Nursing staff interviews revealed inconsistent and uncorroborated accounts of whether wound care was actually performed on those days. RN A stated she last dressed the wounds on 2/23/26 and could not explain the lack of documentation; no other staff could confirm that wound care occurred that day. LVN E claimed she performed wound care on 2/24/26 but admitted she did not document it in the TAR, stating she could not find the resident’s name and did not seek assistance from other nurses. CNA and nurse interviews about wound care performed on 2/26/26 indicated that the dressings still bore RN A’s initials from the prior treatment and appeared unchanged for 2–3 days, with staff noting a bad odor and drainage from the left hip wound. On 2/27/26, observations and interviews documented that the resident’s room had a strong foul odor, which staff attributed to his wounds. During wound care that day, the Wound Care Doctor found the right hip wound to be very dark with mostly eschar and moderate drainage, and described the left hip wound as unstageable, very smelly, and appearing infected, with purulent and serosanguinous drainage and a yellow-tinged exudate that suggested depth. The left hip wound measured larger than previously documented and was diagnosed as infected. The Wound Care Doctor stated that if the resident had received wound care on the missed days, it could have helped prevent the decline of the left hip wound, although he could not say the infection was unavoidable due to the resident’s comorbidities and poor nutrition. Hospice staff also stated that while the resident’s wounds were considered unavoidable due to his condition, having wounds that were not being treated constituted neglect and that infections were avoidable. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to provide necessary pressure ulcer treatment and services as ordered.
Removal Plan
- Resident #1 was immediately assessed by the Wound Care Doctor and diagnosed with an infected unstageable pressure ulcer to the left hip.
- Physician orders were obtained for Clindamycin 450 mg three times daily for 14 days to treat the wound infection.
- Wound care resumed immediately per physician order (daily day shift treatment).
- Wound cultures were ordered and obtained.
- The DON initiated direct oversight of wound care completion and documentation.
- The facility reviewed the census and identified all residents with wounds.
- A 100% audit was completed of all wound treatment orders and TAR documentation.
- Head-to-toe skin assessments were completed for all current residents.
- Any identified documentation gaps were immediately corrected and treatments were provided.
- All licensed nurses were re-educated on the wound care policy, including treatment frequency, dressing type, and documentation requirements.
- Staff education included expectations for notifying the physician of any changes in wound condition.
- A daily wound care assignment sheet was implemented to ensure accountability.
- The DON or designee will perform daily spot checks of wound treatments.
- A daily audit of all wound treatments will be conducted for 14 days.
- Weekly audits will be conducted thereafter for 30 days.
- Audit results will be reviewed in the QAPI meeting.
- Staff failing to follow wound care procedures will receive immediate counseling and retraining.
- The facility will verify that all residents are receiving wound care as ordered, all licensed nurses have completed re-education, and monitoring systems are in place and functioning to ensure ongoing compliance.
Failure to Initiate CPR for Full Code Resident Due to Incorrect Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to provide basic life support, including CPR, to a resident who was a documented Full Code prior to the arrival of emergency medical personnel. The resident, an elderly male with dementia, cerebral infarction (stroke), and COPD, was admitted under hospice services with orders that Hospice A be notified of any change in condition. His advance directives and physician orders identified him as Full Code with CPR to be initiated if his heart or breathing stopped. However, his MDS assessment and care plan did not document his Full Code status, and his code status was incorrectly listed as DNR in the code status binder at the nurse’s station. On the day of the incident, the resident’s vital signs were incompletely documented, with no blood pressure, temperature, pulse, or respirations recorded, although an oxygen saturation of 99% via nasal cannula was documented by LVN A in the afternoon. The resident had a BIMS score documented as staff-assessed, and a progress note indicated he was moderately impaired but able to make decisions regarding tasks of daily life. Later that day, CNA B found the resident unresponsive in bed while passing dinner trays, noting that his skin appeared yellow and he did not respond to touch or verbal stimuli. CNA B immediately informed LVN A that the resident was unresponsive and not breathing. LVN A reported that upon entering the room, she assessed the resident, took his pulse and blood pressure, but did not document the readings and could not recall them. She confirmed that the resident was unresponsive, warm to the touch, and without respirations or detectable airway movement. Despite the resident’s actual Full Code status in the medical record and hospice documentation, LVN A did not initiate CPR because she relied on the code status binder, which incorrectly listed the resident as DNR. She contacted the nurse practitioner and DON to report the resident’s death and misidentified the deceased resident as a different individual. Hospice A later confirmed that the resident had always been Full Code with their agency and that he had personally signed the Full Code documentation. The facility’s CPR policy required CPR to be performed if a resident did not show obvious signs of clinical death, but no CPR was initiated for this resident, and hospice was not notified at the time of death.
Failure to Protect EMR Confidentiality and Provide Requested Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to safeguard confidential electronic medical records and to provide a resident’s medical records upon repeated written requests. On Hall C, a computer mounted to the wall was observed logged into the medical record system under a CNA’s user account and left unattended. The CNA’s name was visible on the screen, and the OT who observed the computer stated that the CNA should not have logged into the system and left it unattended because it contained private resident records and orders. The ADON and DON both stated that the computer should not have been left logged in, as unauthorized individuals could access resident information, including social security numbers, home addresses, and diagnoses. When a different CNA later logged into the same computer, the DON confirmed that from the home screen staff did not need an additional password to access resident records. The deficiency also includes the facility’s failure to respond to multiple written requests for a deceased resident’s medical records submitted by the resident’s representative through an outside entity. Five letters, each containing a certified and first-class mailing, were sent to the facility’s President/CEO or the facility’s parent company, requesting the resident’s complete medical record for a specified time period and including an authorization form for release of protected health information signed by the resident’s representative. The letters also included a copy of the resident’s death certificate and the representative’s state ID. Postal tracking showed that some letters had not reached their destination, one was returned to sender, and one was received and signed for at a postal facility. The facility had undergone a name change, but the parent company remained the same. Record review showed that the resident was an older male with multiple serious medical diagnoses, including anemia, Parkinsonism, pressure ulcers, Alzheimer’s disease, quadriplegia, dysphagia, acute respiratory failure with hypoxia, and pneumonia. He was coded on the MDS as rarely or never understood, with short- and long-term memory problems and total dependence on staff for all ADLs. Staff interviews revealed that the social worker, medical records staff, and business office managers (both current and former) denied receiving or being aware of any medical records requests for this resident. The Administrator, who had been in his position for about a month, described a process in which the DON would send medical records requests to the business office manager and stated that if mail was addressed to the previous company, he would not sign for it and the letters would be sent back. He reported that the facility did not receive any mail or letters related to this resident, despite the documented mailings and statutory requirements under Texas Civil Practice and Remedies Code Sections 74.051 and 74.052 for providing medical records within a specified timeframe after receipt of a written request accompanied by a proper authorization.
Failure to Administer Prescribed IV Antibiotics After Hospital Readmission
Penalty
Summary
A significant medication error occurred when a resident returned to the facility from the hospital and did not receive prescribed IV antibiotics, including Vancomycin and Meropenem, as ordered by the hospital physician. The resident, who had multiple complex medical conditions such as respiratory failure, sepsis, pneumonia, and a tracheostomy, was supposed to continue IV antibiotic therapy upon readmission. However, due to a lack of communication and incomplete transfer of clinical records, the antibiotics were not administered for several scheduled doses. The admitting nurse did not receive a report from the hospital at the time of the resident's return and did not take further steps to obtain the necessary information, such as contacting the hospital, the ADON, or the Administrator. As a result, the resident's medication administration record (MAR) did not include the required antibiotics, and the medications were not initiated until the following evening, resulting in four missed doses. The ADON and other staff members later confirmed that the omission was due to missed communication and oversight in reviewing updated clinical records sent by the hospital. Interviews with facility staff revealed that the absence of a Clinical Marketer and the lack of a clear process for handling admissions without a hospital report contributed to the breakdown in communication. The Business Office Manager had attempted to facilitate the transfer of information, but the updated medication list was not reviewed in a timely manner. The resident's physician was eventually notified of the missed doses and adjusted the treatment plan accordingly.
Failure to Ensure Clean and Safe Environment Prior to Resident Readmission
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident who was readmitted from the hospital. Upon the resident's return, the room had not been cleaned prior to admission, as required by facility policy. Observations revealed that the resident's room contained a used bottle of enteral feeding, respiratory supplies, white sand-like debris on the nightstand, a used suction catheter in the nightstand drawer, and debris on the floor and under the bed. Additionally, the second bed in the room was unmade, with stained sheets and a used alcohol swab present. Interviews with staff confirmed that the room was not cleaned before the resident's readmission. The CNA and RN both stated that the room was dirty and disorganized, and neither knew who had placed certain items, such as disinfectant wipes, in the room. The RN admitted to attempting to clean the room herself upon the resident's arrival, as there were no clean sheets on the bed, and she had to use linens from the other bed. The respiratory therapist also confirmed that used suction tubing should have been discarded but was found in the resident's drawer. Further interviews with housekeeping staff and the Housekeeping Director revealed a lack of clear communication regarding the need to clean the room prior to the resident's readmission. The Housekeeping Director stated that rooms should be deep cleaned and disinfected after discharge and before admission, but this process was not followed due to a communication gap. The facility's policy on resident rights affirms the right to a safe, clean, and comfortable environment, which was not upheld in this instance.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow Enhanced Barrier Precautions (EBP) while providing direct care to a resident with multiple complex medical conditions, including a gastrostomy tube, end stage renal disease, and severe cognitive impairment. The resident was under physician orders for EBP, which required staff to don a disposable gown and gloves when providing care. On the observed date, signage indicating EBP requirements was posted on the resident's door, and personal protective equipment (PPE) was available at the entrance. Despite these measures, the CNA admitted to not wearing a disposable gown while performing incontinent care for the resident, stating she was in a hurry to prepare the resident for dialysis. The facility's Assistant Director of Nursing (ADON), who also served as the Infection Control Preventionist, confirmed that all staff were expected to use gloves and gowns when providing care to residents with devices such as gastrostomy tubes. The ADON acknowledged that failure to don appropriate PPE during care increased the risk of cross-contamination. Review of the facility's infection prevention and control policy indicated that the facility was required to maintain an infection control program in accordance with national standards, which was not followed in this instance.
Failure to Protect Residents from Abuse and Inadequate Behavioral Interventions
Penalty
Summary
The facility failed to protect residents from abuse, neglect, and exploitation, specifically involving two residents with histories of aggressive and inappropriate behaviors. One resident, with severe cognitive impairment and a history of mood disorders and aggression, was involved in multiple incidents, including a physical altercation with a roommate and an episode of inappropriate sexual behavior toward another resident. Despite documentation of these behaviors in progress notes and care plans, the care plan did not address sexually inappropriate behavior, and interventions for aggressive conduct were inconsistently implemented or documented. Staff interviews revealed a lack of awareness and follow-up regarding the sexual incident, and the psychiatric provider was not notified of the event, missing an opportunity for timely intervention. Another resident, with moderate cognitive impairment and a history of depression, suicidal behavior, and aggression, was also involved in the physical altercation. This resident had previously exhibited verbal and physical aggression toward roommates and staff, including threats and throwing objects. The care plan and psychological notes did not address these behaviors or the altercation, and there was no evidence of comprehensive behavioral interventions or adjustments following repeated incidents. Staff interviews indicated that both residents were known to be incompatible as roommates due to their aggressive tendencies, yet they were placed together, leading to a physical altercation resulting in injury and an ER visit. The facility's investigation and documentation of the incidents were incomplete. The Provider Investigation Report lacked staff statements and did not indicate whether law enforcement or the Ombudsman were notified. Staff interviews revealed inconsistent reporting and follow-up on behavioral incidents, and there was no evidence of increased supervision or staffing adjustments after the altercation. Facility policies required immediate safety strategies and thorough investigations, but these were not fully implemented, leaving residents at risk of harm from abuse and neglect.
Failure to Prevent G-Tube Dislodgement in Residents with Behavioral Risks
Penalty
Summary
The facility failed to ensure that residents receiving enteral nutrition via feeding tubes received appropriate treatment and services to prevent complications related to tube dislodgement. Two residents with a history of restlessness and behaviors such as pulling on or removing their G-tubes did not have adequate interventions in place, such as abdominal binders, to prevent repeated dislodgement of their feeding tubes. This resulted in multiple incidents where the residents pulled out their G-tubes, requiring hospitalization for tube replacement, and in one case, an IV pole fell on a resident's head during an episode of pulling on the tube, causing injury. For one resident, medical records indicated a history of severe cognitive impairment, dependence on staff for all care, and ongoing behaviors including agitation and attempts to pull out her G-tube. Despite these documented behaviors and multiple incidents of tube dislodgement, the resident's care plan did not address the risk of G-tube removal or include interventions such as an abdominal binder. Staff interviews confirmed that the resident was known to be restless and to pull on her tube, but no consistent preventive measures were implemented prior to the incidents. A second resident with similar cognitive and behavioral issues also experienced multiple episodes of G-tube dislodgement, leading to repeated hospitalizations. The care plan and physician orders for this resident did not include the use of an abdominal binder or other interventions to address the risk of tube removal until after several incidents had already occurred. Staff interviews and record reviews revealed a lack of communication and documentation regarding these behaviors, and the care plans were not updated to reflect the residents' needs for preventive interventions until after the deficiencies were identified by surveyors.
Failure to Provide Appropriate Mental Health Treatment and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with mental disorders or psychosocial adjustment difficulties, as evidenced by multiple incidents involving three residents. One resident with a history of schizoaffective disorder, bipolar disorder with severe psychotic features, and paraplegia exhibited escalating behaviors, including frequent calls to 911, verbal aggression, yelling, and a suicide attempt. Despite documented behaviors and repeated hospitalizations, there were no behavior monitoring or intervention orders in place, and staff were unaware of the resident's extensive history of suicide attempts and aggressive behaviors. The care plan did not adequately address the resident's risk for self-harm or aggression, and the interdisciplinary team failed to review or act upon hospital discharge records detailing the resident's psychiatric history and recent suicide attempt. Another resident with schizophrenia and anxiety disorder demonstrated severely impaired cognition and exhibited aggressive behaviors, including yelling, cursing, throwing objects, and making suicide threats. The care plan did not address suicidal behavior or suicide threats, and there was no evidence of behavior monitoring or interventions specific to these risks. Staff documented multiple incidents of physical and verbal aggression, as well as statements of intent to self-harm, but interventions were limited to medication administration and attempts at verbal redirection, which were often unsuccessful. The facility did not implement comprehensive behavioral interventions or monitoring to address the resident's escalating behaviors and suicide threats. A third resident displayed continuous behaviors such as pacing, banging on doors, and intrusive interactions with other residents and staff, but the facility failed to provide treatment and services to correct these behaviors. The lack of appropriate interventions and monitoring for residents with significant mental health and behavioral needs resulted in repeated incidents requiring emergency intervention, including police involvement and physical restraint. The facility's failure to assess, monitor, and address the residents' mental and psychosocial needs placed residents at risk for harm and did not support their highest practicable mental and psychosocial well-being.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live pests in multiple areas. Observations revealed live gnats in the shower room on Hall C and on a towel placed on a resident's abdomen in Room D11, with additional gnats circling around the resident. The gnats remained undisturbed even when the towel was removed and discarded. Further observations identified gnats flying in the Hall C shower room and a cockroach running across the counter at the C & D Hall nursing station, which was killed by an RN. Staff interviews confirmed awareness of the pest issue, and pest control records indicated that the most recent treatment focused on the kitchen area, not the affected locations. The facility's pest control policy states that an ongoing program is maintained to keep the building free of insects and rodents. However, the presence of gnats and cockroaches in resident care and staff areas demonstrates a failure to implement the policy effectively. The deficiency was identified through direct observation, staff interviews, and review of pest control service records, which did not reflect comprehensive or recent treatment of the problem areas.
Failure to Thoroughly Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide evidence that an alleged violation involving a resident-to-resident altercation was thoroughly investigated. Specifically, there was no documentation indicating whether the Ombudsman or law enforcement were notified, and the investigation lacked witness statements from staff members. The incident involved two residents in a secure unit, one of whom reported being hit in the eye by his roommate, resulting in redness to the eyelid. The event was not witnessed by staff, but immediate actions were taken to separate the residents and notify the Director of Nursing (DON) and Social Worker (SW). Both residents involved had histories of dementia and behavioral issues, including verbal and physical aggression and wandering. One resident had a BIMS score indicating severe cognitive impairment, while the other had moderate impairment and hemiplegia. The care plans for both residents did not fully address the aggressive behaviors or the specific altercation, and documentation showed that one resident was moved to another room following the incident. Progress notes indicated that staff observed threatening behavior and physical aggression, but the facility's Provider Investigation Report (PIR) did not include required notifications or staff interviews. Interviews with the interim and previous administrators revealed inconsistencies in reporting and investigation practices. The interim administrator stated that abuse allegations should be reported to the state, Ombudsman, and police, and that staff interviews should be conducted, but she was unable to locate the full investigation report. The previous administrator claimed to have completed an internal investigation and staff interviews but did not report the incident to law enforcement, citing the residents' dementia and confusion. The facility's abuse and neglect policy required immediate reporting and notification of law enforcement for reasonable suspicion of a crime, but there was no evidence these steps were followed.
Widespread Failure to Provide Clean Linens, Hot Water, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, comfortable, and homelike environment for all residents, as evidenced by widespread lack of clean bed and bath linens, inadequate hot water for bathing, and missing privacy curtains in multiple rooms. Observations revealed that numerous residents were found lying on bare mattresses due to a shortage of linens, with linen closets across all halls frequently empty. Residents and staff consistently reported that the facility's washing machines had been broken for weeks, resulting in laundry being sent to a local laundromat, which did not meet the needs for timely and adequate linen supply. Additionally, hot water was unavailable or insufficient in several resident rooms and shower areas, leading to residents receiving cold or no showers. Multiple residents, including those with significant medical needs such as skin breakdown risk, incontinence, and limited mobility, reported feeling unclean, cold, and neglected due to the lack of clean linens and inability to bathe properly. Some residents expressed emotional distress, with one resident becoming tearful and describing the situation as inhumane. Staff interviews corroborated these findings, noting that the lack of linens, towels, and other essential supplies made it difficult to provide proper care, and that residents sometimes had to use towels as briefs or go without necessary hygiene items. Staff also reported that the process for returning personal clothing from the laundromat was unreliable, leading to lost items and further resident dissatisfaction. Environmental observations further documented that privacy curtains were missing in several rooms, compromising resident privacy. Maintenance staff confirmed ongoing issues with the facility's hot water system, and housekeeping staff noted that trash had not been picked up for extended periods, contributing to unsanitary conditions. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or emotional distress, yet the documented actions and inactions resulted in residents experiencing discomfort, lack of dignity, and inadequate support for daily living.
Widespread Neglect Due to Lack of Linens, Hot Water, and Care Supplies
Penalty
Summary
The facility failed to protect all residents from neglect by not providing adequate clean linens, towels, and essential care supplies across all units. Multiple residents were observed lying on bare mattresses due to a lack of linens, and several reported feeling cold, unclean, dirty, and neglected. The facility's washing machines had been broken for an extended period, resulting in laundry being sent to a local laundromat, which led to delays and loss of personal clothing. Staff interviews confirmed ongoing shortages of linens, towels, briefs, gloves, and wipes, making it difficult to maintain resident hygiene and comfort. Some staff reported using towels as makeshift briefs or sheets, and residents sometimes went without showers due to a lack of hot water or clean towels. Residents with significant medical needs, such as those with paralysis, chronic wounds, incontinence, and at risk for skin breakdown, were particularly affected. Several residents expressed emotional distress, with one resident crying and describing the situation as inhumane. Observations and interviews revealed that the lack of clean linens and hot water persisted for weeks, and residents often had to wait for clean items to be returned from the laundromat. Staff also reported that the process for returning personal clothing was unreliable, leading to further resident dissatisfaction and loss of dignity. The facility also failed to provide hot water in resident rooms and showers, resulting in residents receiving cold or no showers. Water temperature checks confirmed that several rooms and shower areas had only lukewarm water. Additionally, there were insufficient supplies for resident care, including briefs, gloves, and wipes, which further compromised the ability to provide adequate care. Staff interviews indicated that these shortages were ongoing and affected all shifts, with some staff bringing their own gloves to work. The cumulative effect of these failures led to widespread neglect, as defined by the facility's own policies and federal regulations.
Failure to Implement Care Plan for Contracted Hand
Penalty
Summary
A deficiency was identified when staff failed to follow the care plan for a male resident with a history of stroke, hemiplegia, and multiple chronic conditions, including functional quadriplegia and contractures. The resident's care plan required the application of a hand roll to his contracted left hand daily, as well as passive range of motion (ROM) exercises. During observation, the resident was found in bed with his left hand severely contracted and without a hand roll in place. The resident reported that he previously had a hand roll, but it had been lost and not replaced. Interviews with staff revealed uncertainty about who was responsible for ensuring the hand roll was in place and why it was missing. Record review showed that the care plan did not address the resident's left hand contracture or nail care, focusing instead on bilateral feet contractures and general ADL deficits. The care plan included interventions for ROM and the use of a hand roll, but these were not implemented as required. Staff interviews indicated a lack of clarity regarding care plan responsibilities and the importance of the hand roll in preventing further contracture and maintaining skin integrity. Facility policy required comprehensive, person-centered care plans with measurable objectives, but this was not followed in the resident's case.
Failure to Provide Follow-Up Care and Documentation After Resident Hand Injury
Penalty
Summary
A deficiency occurred when a male resident with multiple complex medical conditions, including hemiplegia, functional quadriplegia, and dependence on staff for most activities of daily living, sustained an injury to his left hand middle finger. The injury happened when two CNAs quickly removed his long sleeve shirt due to an ant being on him, causing his finger to get caught, resulting in pain and significant bleeding. The resident reported that the nurse clipped the damaged fingernail and that a wound care nurse applied a dressing, but he was unsure of the exact date or the staff involved. Upon observation, the resident's left hand middle finger was found wrapped in an undated dressing secured with scotch tape, with a visible red spot indicating bleeding. The resident described ongoing soreness in the finger. The Director of Nursing (DON) was unaware of the injury and, upon removing the dressing, observed a large cut below the nail bed with no active bleeding but noted the resident's pain and the presence of thick, dried, bumpy skin on the fingertip. The DON acknowledged that the injury had not been reported or documented as required. Record review revealed no physician orders for treatment of the finger, no change in condition forms, no accident or incident reports, and no skin assessments addressing the injury. The resident's care plan did not address hand contractures, nail care, or the specific injury. Facility policy required prompt investigation and reporting of all accidents or incidents, but this process was not followed in this case, resulting in a lack of appropriate follow-up care and documentation for the resident's injury.
Failure to Accurately Assess and Document Upper Extremity Impairment
Penalty
Summary
The facility failed to accurately assess and document a resident's upper extremity impairment in both the Minimum Data Set (MDS) and the care plan. The resident, a male with a history of stroke, hemiplegia, hemiparesis, and functional quadriplegia, was observed to have a contracted left hand and reported that his left hand did not function due to a previous stroke. Despite these significant impairments, the quarterly MDS did not reflect any upper extremity functional limitation or contractures, and the care plan only addressed contractures in the feet, omitting the hand contracture and related care needs. During interviews, the MDS nurse acknowledged missing the upper extremity impairment in the MDS, although she believed it was included in the care plan, which was not the case. The Chief Nursing Officer (CNO) confirmed that the MDS is a multidisciplinary assessment tool intended to drive the plan of care and that missing information could result in missed care opportunities. The CNO also noted that therapists should educate nursing staff on interventions such as splint use, but this was not documented or implemented for the resident. Facility policy requires comprehensive, person-centered assessments and care plans that address all physical, psychosocial, and functional needs, using information from multiple sources. In this case, the assessment and care planning process did not capture or address the resident's upper extremity impairment, resulting in incomplete documentation and potentially inadequate care planning for the resident's needs.
Failure to Provide Nail Care and Personal Hygiene Services
Penalty
Summary
A deficiency occurred when the facility failed to provide necessary nail care and personal hygiene services to a resident who was unable to perform activities of daily living independently. The resident, a male with a history of acute respiratory failure, hemiplegia, hemiparesis, stroke, functional quadriplegia, and other significant medical conditions, was cognitively intact but required substantial assistance with personal hygiene and was totally dependent for lower body dressing. Observations revealed that the resident had long, dirty fingernails on both hands, with one hand contracted and a finger wrapped in an undated dressing. The resident reported that his finger was injured when it got caught on his shirt as two CNAs quickly removed his clothing, resulting in pain, bleeding, and the need for the nurse to clip the damaged nail. Interviews with staff indicated a lack of awareness and responsibility regarding the resident's nail care and the injury. The CNA interviewed was unaware of the injury and acknowledged the resident's nails needed cleaning and trimming, noting the risk of infection. An LVN stated she was unsure who was responsible for nail care and was unaware of the injury, while the DON indicated that nursing staff were responsible for nail care and that periodic rounds should be conducted to monitor residents' needs. However, there was no clear documentation or evidence that nail care was being provided or monitored for this resident. Record reviews showed no physician orders for nail care, no documentation of nail care or refusals in the resident's progress notes or ADL reports, and the care plan did not address the resident's hand contractures, nail care, or the skin injury to the finger. Facility policies required prompt documentation and notification of changes in condition, as well as regular skin assessments and investigation of incidents, but these were not followed in this case, as there was no documentation of the injury or related care in the resident's records.
Environmental Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed that multiple resident bathrooms had loose toilets and sinks that were dislodging from the wall in several rooms. Additionally, the window screen in one resident room was found to be cut open with jagged edges, and the windowpanes were held in place with duct tape, some of which was aged and dirty. There was also evidence of leaves and dirt accumulating between the screen and the window. The outside trash dumpster area was observed to have trash bags, boxes, and other debris on the ground, with the trash bin too full to close properly. Staff and residents reported that the trash had not been picked up for an extended period, resulting in an unpleasant odor and sightings of rodents around the area. The trash was located near a frequently used entrance, and the smell was reported to be noticeable inside the facility as well. Maintenance issues were also identified regarding the facility's hot water supply. Multiple resident rooms and common areas were found to have water temperatures below the required range, following a circulation pump failure that was not immediately resolved. Maintenance staff acknowledged the importance of maintaining appropriate water temperatures for resident hygiene and health, and facility policy required regular checks and documentation of water temperatures, which were not consistently met during the period in question.
Failure to Document and Report Resident Injury
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who sustained an injury to his left middle finger. The resident, who had multiple diagnoses including acute respiratory failure, hemiplegia, functional quadriplegia, and was cognitively intact, was observed with a contracted left hand and a dressing on his middle finger. The dressing was undated, and the resident reported that the injury occurred when his finger got caught on his shirt as two CNAs quickly removed his long sleeve shirt due to an ant being present. The resident stated the incident was painful, resulted in bleeding, and required the nurse to clip the damaged fingernail and apply a dressing. He also reported receiving pain medication after the incident, but could not recall the exact date or the names of the staff involved. Upon review of the resident's medical chart, there was no documentation of the injury, no change in condition form, no accident or incident report, and no skin assessment addressing the injured finger. The care plan did not address the skin injury, hand contractures, or nail care, and only referenced bilateral feet contractures and ADL self-care deficits. Interviews with nursing staff, including an LVN, the DON, and the CNO, revealed that none were aware of the injury, and all confirmed that there was no documentation or incident report related to the event. The facility's policies required prompt documentation and reporting of accidents, incidents, and changes in condition, as well as updating care plans and notifying the physician and family, but these procedures were not followed in this case. The lack of documentation and failure to follow established policies resulted in incomplete and inaccurate medical records for the resident. This omission was identified through observation, interview, and record review, and was found to be inconsistent with accepted professional standards and practices for maintaining resident medical records.
Resident Burned by Hot Coffee Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for a resident, resulting in a burn injury. The resident, who had a history of dementia, schizoaffective disorder, muscle wasting atrophy, and spastic hemiplegia, was served coffee at an unsafe temperature. The resident, who required supervision while eating, received a hot cup of coffee without a lid, leading to a spill and subsequent burn on her left hand. The incident was reported by the resident to the nursing staff, who observed reddened skin and provided immediate care. The facility did not maintain a temperature log for coffee prior to distribution, which contributed to the incident. The dietary staff member involved, who was not fully trained on the specifics of serving coffee, provided the resident with a fresh batch of coffee without verifying the temperature. The staff member claimed to have placed a lid on the cup, but the resident reportedly removed it, leading to the spill. The lack of proper training and documentation of coffee temperatures were significant factors in the occurrence of the burn. Interviews with staff revealed that the dietary manager had not conducted in-service training related to coffee temperature management prior to the incident. The dietary manager and staff were unaware of the risks associated with serving hot beverages at high temperatures. The facility's policy on hot liquids emphasized the need for safety evaluations and interventions for residents with conditions that increase the risk of burns, but these measures were not effectively implemented, resulting in the resident's injury.
Failure to Ensure Safety and Supervision Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards and did not provide adequate supervision for two residents, leading to deficiencies in care. Resident #4, a female with severe cognitive impairment and a history of falls, did not have a fall mat in place at her bedside as required by her care plan. Observations on multiple occasions confirmed the absence of the fall mat, and staff interviews revealed confusion and lack of communication regarding the necessity of the mat. The DON acknowledged the oversight and indicated that the fall mat was an intervention to prevent injury, although it would not prevent falls. Resident #10, a male with severe cognitive impairment and multiple health issues, was left unattended in his wheelchair for an extended period, resulting in a fall. Despite being at risk for falls due to his condition, staff failed to provide the necessary supervision. Video footage showed that he was left alone in his room for over three hours, during which he fell and sustained a head injury. Interviews with staff revealed a lack of awareness and communication about the resident's fall risk and the need for supervision while in the wheelchair. The facility's policies on fall risk management and wheelchair safety were not adequately followed, contributing to the incidents. Staff interviews highlighted inconsistencies in understanding and implementing care plans and safety measures. The facility's failure to adhere to its policies and ensure proper supervision and safety interventions placed residents at risk of injury.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for Resident #1, who was a [AGE] year-old male with a history of Type 2 diabetes mellitus, anemia, muscle wasting, and sepsis. Despite a podiatrist consult being noted in the resident's progress notes on 6/10/2024, Resident #1 did not receive podiatry services to have his toenails trimmed. Observations revealed that his toenails were extended and curled past the toenail bed, approximately 1/2 inch long, with dry and flaky skin on his feet. Resident #1 expressed discomfort and a desire to have his toenails cut, which had not been done since his admission to the facility. Interviews with facility staff, including an LVN, SW, MDS RN, DON, NP, and the Administrator, highlighted a lack of communication and follow-through in ensuring Resident #1 received necessary podiatry services. The SW was responsible for adding residents to the podiatry service list, but Resident #1 was not included despite the documented need. The DON and NP acknowledged the risk of infection and skin issues due to the resident's elongated toenails, especially given his diabetic condition. The facility's policy indicated that podiatry services should be facilitated through the Social Service Department, but this was not effectively executed. The facility's failure to provide timely podiatry care for Resident #1 was a result of inadequate coordination and communication among staff members. The resident's toenails were not monitored or addressed during routine skin assessments and shower reviews, leading to a neglect of his foot care needs. This oversight placed Resident #1 at risk for complications, particularly due to his diabetes and the potential for ingrown toenails to cause infection.
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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