Bel Air At Teravista
Inspection history, citations, penalties and survey trends for this long-term care facility in Round Rock, Texas.
- Location
- 4105 Teravista Club Drive, Round Rock, Texas 78665
- CMS Provider Number
- 676345
- Inspections on file
- 49
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Bel Air At Teravista during CMS and state inspections, most recent first.
A resident with advanced dementia and multiple comorbidities had a longstanding insulin regimen for type 2 DM discontinued and replaced with Metformin by an NP without prior notification to or consent from the resident’s family. Facility records showed the sequence of orders changing from Lantus to varying doses of Metformin and later back to insulin, with MARs indicating medications were given as ordered. The family later reported the resident developed symptoms they associated with Metformin and stated they would not have agreed to the change if informed. In interviews, the NP admitted she did not consult the family before changing the treatment, acknowledged this was a mistake, and recognized the resident’s and family’s right to be informed of treatment changes, risks, benefits, and alternatives. The MD and DON confirmed that the NP failed to communicate the medication change to the family, and staff described that residents have the right to know about medication changes and to accept or refuse treatment, demonstrating a failure to follow the facility’s resident rights policy.
A resident with Type 2 DM, hypothyroidism, bipolar disorder, and anxiety, who had moderate cognitive impairment and required some assistance with ADLs, had physician orders and a care plan for Insulin Lispro with specific blood glucose parameters to hold doses. Review of the MAR and a DON audit showed that an LVN administered insulin on multiple occasions when the resident’s blood sugar readings were below the ordered threshold, including a dose given when readings were documented as outside parameters, while another scheduled dose was not given. The resident had generally good meal intake during this period and later developed stroke-like symptoms and was sent to the hospital, where hypoglycemia was diagnosed; an NP noted that the short-acting insulin given earlier would have worn off by the following morning and could not be clearly linked to the low blood sugar.
A resident with multiple serious conditions and moderate cognitive impairment had new pain management orders including scheduled Robaxin, PRN Tramadol, and a Fentanyl patch, while Hydrocodone was discontinued. The charge LVN received the updated orders and entered the discontinuation of Hydrocodone but failed to enter the scheduled Robaxin order into the electronic system, resulting in missed doses and delayed initiation of the medication. The MAR showed gaps in Robaxin administration, and the DON confirmed that Robaxin and Tramadol were not provided as ordered, despite facility policy requiring timely and accurate documentation and implementation of new medication orders. The resident and family reported concerns about pain control during this period.
Multiple residents with respiratory conditions were observed to have nebulizer masks and oxygen cannulas left exposed on surfaces or the floor, rather than stored in protective bags as required for sanitation. Staff interviews revealed a lack of training and inconsistent practices regarding the storage of respiratory equipment, and the facility's policy did not address this requirement.
A resident with severe cognitive impairment and a UTI was started on a new antibiotic, but the responsible party was not notified as required by facility policy. Review of records and staff interviews confirmed that nursing staff did not inform or document communication with the family regarding the new medication order.
The facility did not complete required discharge summaries and recapitulation of stay documents for three residents, resulting in missing or incomplete information such as nursing services, therapy plans, medication disposition, and patient education. Staff interviews confirmed that discharge documentation was not consistently completed or verified, and family members reported not receiving necessary paperwork or follow-up information at discharge.
Multiple residents with serious infections did not receive their prescribed antibiotics as ordered, with missed and late doses documented. Despite established protocols and the use of pharmacy automation, lapses in medication reconciliation, order entry, and communication between hospital discharge paperwork and the facility's EMR led to these deficiencies. Nursing and leadership staff were not consistently informed of missed or late doses, contrary to facility policy.
Surveyors identified failures in food storage, preparation, and service, including undated and expired food items, unclean utensil drawers, dirty fryer grease, inconsistent food temperature monitoring, and lapses in hand hygiene by staff during meal service. These actions and inactions resulted in a deficiency related to food service safety standards.
A resident with multiple complex medical conditions did not have pharmacy consultant medication recommendations received or acted upon due to an email delivery failure, resulting in a delay in reviewing and implementing suggested medication changes. Facility leadership confirmed that the process for ensuring receipt and follow-up of pharmacy recommendations was not followed as required by policy.
A CNA in a LTC facility attempted to transfer a resident without the required mechanical lift and two-person assistance, as specified in the resident's care plan. The resident, who had multiple health issues, was lowered to the floor when the transfer was unsuccessful. Despite being aware of the transfer requirements, the CNA proceeded alone due to the absence of other staff. The resident later complained of arm pain, and an x-ray revealed a humeral fracture.
A medication aide in an LTC facility failed to supervise a resident during medication administration, leaving the medication with the resident without observing its intake. The resident, who was cognitively intact, did not have a self-administration assessment or care plan. Staff interviews confirmed the requirement for supervision unless a self-administration assessment is documented.
A resident with severe cognitive impairment eloped from the facility, resulting in a fall and facial injuries. Despite being assessed as a moderate elopement risk, the resident exited through the front door unnoticed. The facility's failure to supervise and monitor the resident adequately led to this deficiency, highlighting a lapse in staff communication and policy implementation.
The facility failed to ensure the resident call system was accessible to three residents, potentially endangering their health or safety. Observations revealed call lights on the floor, and interviews indicated staff awareness but inconsistent adherence to protocols.
The facility failed to maintain resident room water temperatures at a comfortable warm level, affecting six residents. Observations revealed water temperatures significantly below the required 100 degrees Fahrenheit, leading to discomfort and refusals of showers. Despite awareness and attempts to resolve the issue since a winter freeze in January, the problem persisted, impacting residents' personal hygiene and comfort.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed undated and unsealed food items in storage and improper beard covering by a cook during lunch service. Interviews confirmed lapses in food safety protocols.
The facility failed to maintain proper infection control during catheter and PICC line care for two residents. Staff did not follow sterile techniques, mishandled supplies, and failed to change gloves when necessary, increasing the risk of infection.
Failure to Inform Resident/Family of Diabetes Medication Change and Obtain Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident and the resident’s family member were informed of and allowed to participate in decisions regarding a significant change in diabetes treatment. The resident was an elderly male with multiple diagnoses including dementia, dysphagia, type 2 diabetes mellitus, hypothyroidism, protein-calorie malnutrition, muscle wasting, acute kidney failure, adult failure to thrive, hemiplegia/hemiparesis, and muscle weakness. His MDS indicated he was rarely or never understood and required substantial assistance with eating, oral hygiene, and personal hygiene. His care plan for diabetes included providing diabetes medications as ordered and monitoring and documenting side effects and effectiveness. Record review showed that the resident had been receiving Lantus (insulin glargine) 8 units subcutaneously at bedtime for diabetes until it was discontinued in mid-January and replaced with Metformin. Orders reflected a sequence of Metformin prescriptions: Metformin 500 mg twice daily, then Metformin 1000 mg every morning and at bedtime, followed by a later order to restart insulin glargine 6 units at bedtime with parameters to hold for blood sugar less than 100. Medication administration records for January and February showed that medications were administered as ordered. The facility’s own resident rights policy required that residents be informed of and participate in their treatment, including being informed by the physician or other practitioner of the risks and benefits of proposed care, treatment alternatives, and options, and being allowed to choose their preferred option. During interviews, the family member reported that the resident had been on insulin for a long time without issues and that, in mid-January, the NP discontinued insulin and started Metformin without informing the family or obtaining consent. The family member stated the resident was on Metformin for about two weeks and then developed swollen lips and throat, decreased appetite, dysphagia, stomach ulcers, and other complications, and that she would not have allowed the change had she been informed. In a separate interview, the NP acknowledged that she changed the resident’s insulin to Metformin for better diabetes control, based on the resident’s inconsistent blood sugar levels and her assessment that it was safe to start Metformin. She stated she did not consult the family before making the change, admitted this was a mistake, and acknowledged that it was the resident’s and family’s right to know about any change in the treatment plan and to have the risks, benefits, and therapeutic rationale discussed with them. The MD stated he was aware of the Metformin incident and that the NP was supposed to discuss any change in the treatment plan with the family and obtain their consent before initiating it. He indicated that the NP did not discuss the change with him beforehand and that, had she done so, he would have advised her to obtain the family’s consent as part of resident rights. The DON confirmed that the resident’s insulin was changed to Metformin and that the NP did not communicate this change to the family member, who later complained. Nursing staff interviewed described that residents have the right to know what medications they are taking, to be informed of changes, to understand effects and side effects, to be informed of alternative therapies, and to accept or decline medications. The ADM stated that the incident involved a failure to inform the family member of a change in the treatment plan and that the NP did not inform the resident and family about the change, which he identified as inappropriate. These findings collectively show that the facility failed to ensure the resident and family were informed in advance of the risks, benefits, and alternatives of the change from insulin to Metformin and to obtain their consent, in violation of the facility’s resident rights policy.
Insulin Lispro Dosing Errors Outside Ordered Blood Glucose Parameters
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. A female resident with Type 2 Diabetes Mellitus without complications, hypothyroidism, bipolar disorder, and an anxiety disorder was admitted to the facility and had a care plan that included receiving insulin as ordered, with monitoring and documentation for side effects and effectiveness. Her admission MDS dated 12/25/25 showed a BIMS score of 12/15, indicating moderate cognitive impairment, and she required some help with dressing and eating. The resident’s MAR and physician orders reflected an order for Insulin Lispro Injection Solution, 2 units subcutaneously three times a day for Type 2 Diabetes Mellitus, with parameters to hold insulin for blood sugar less than 150 or if the resident was not eating, and a hypoglycemic protocol for finger-stick blood sugar less than 60. Record review and the DON’s audit revealed that between 12/19/2025 and 12/30/2025, the resident was administered insulin on multiple occasions outside the prescribed blood sugar parameters. Specifically, the DON identified that LVN B administered insulin outside of parameters on several dates in December, including when the resident’s blood sugar readings were 117 and 148 on 12/30/2025, which were below the ordered threshold for administration. On that date, the resident received insulin at 11:30 a.m. despite a blood sugar of 117, and did not receive insulin at 5:00 p.m. when the blood sugar was 148, both readings documented as outside the parameters. The resident’s meal intake on 12/30/2025 was recorded as 51–75% for breakfast and lunch and 76–100% for dinner. On 12/31/2025 at 6:30 a.m., the resident was reported to have stroke-like symptoms including lethargy and slurred speech and was transported to the hospital, where the diagnosis was hypoglycemia. An NP later stated that Insulin Lispro is short-acting and that, given the resident’s good food intake, the 11:30 a.m. insulin dose on 12/30/2025 would have worn off by the following morning and could not be definitively linked to the low blood sugar at 6:00 a.m. the next day.
Failure to Accurately Enter and Administer New Pain Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate ordering, entry, and administration of prescribed pain medications for one resident. The resident was an older female admitted with multiple serious diagnoses, including Type 2 diabetes, chronic kidney disease, nonalcoholic cirrhosis, lumbar compression fracture, malignant breast cancer, and recurrent depressive disorders. Her MDS showed moderately impaired cognition (BIMS 12) and functional impairment in both upper extremities. Her care plan stated she would participate in making choices and decisions regarding pain management. Physician orders dated 01/10/2026 at 5:00 p.m. included Tramadol 50 mg by mouth every 6 hours as needed for pain, a Fentanyl 12 mcg/hr patch every 72 hours, and Methocarbamol (Robaxin) 500 mg by mouth every 8 hours for pain, with Hydrocodone-Acetaminophen discontinued at that time. Review of the MAR showed Tramadol PRN was administered on 01/11/2026 at 5:00 p.m., the Fentanyl patch was administered on 01/11/2026 at 7:42 a.m., and the Robaxin order, received on 01/10/2026 at 5:00 p.m., was not entered into the resident’s orders until 01/12/2026, with Robaxin first administered on 01/12/2026 at 12:00 a.m. The MAR reflected one missed dose of Robaxin on 01/11/2026 and two missed doses on 01/12/2026. During interviews, the resident reported that her daughter told her she had not received her pain medication on Saturday night and recalled her pain level as 5 out of 10, though she did not request pain medication and stated she believed the Fentanyl patch was helping. A family member reported the resident was without pain medication from the afternoon of 01/10/2026 until the afternoon of 01/11/2026. The DON stated that Robaxin was ordered and should have been given the same day the order was received, but none was given, and that Tramadol PRN was ordered and not given until later. The DON explained that LVN A changed the orders in the electronic system to discontinue Hydrocodone but forgot to enter the scheduled Robaxin order. LVN A confirmed she received the new orders by text, was responsible for updating the chart, and acknowledged not updating the orders immediately, despite the expectation that new medications be started as ordered. Facility policy required that new medication orders be documented with date, time, and signature, recorded on the physician’s order sheet and MAR, and that changed orders be correctly entered in the electronic system, which did not occur in this case.
Failure to Sanitize and Store Respiratory Equipment Properly
Penalty
Summary
The facility failed to ensure that residents requiring respiratory care received such care in accordance with professional standards of practice. Specifically, for five residents reviewed, nebulizer masks and oxygen cannulas were not stored in protective bags when not in use. Observations revealed that these respiratory devices were left exposed on side tables, beds, or even on the floor, rather than being properly bagged or stored as required for sanitation. In several cases, there were no protective bags available in the residents' rooms, and residents were not educated on the importance of proper storage. The residents involved had significant medical histories, including acute and chronic respiratory failure, COPD, heart failure, and other serious conditions requiring the use of nebulizers and oxygen therapy. Despite physician orders and care plans specifying the use of these devices, staff did not consistently ensure that the equipment was stored in a sanitary manner. Interviews with nursing staff revealed a lack of in-service training on this subject, and some staff admitted to not following proper procedures for storing respiratory equipment. One nurse acknowledged it was her mistake for not ensuring the masks were protected from contamination. The Director of Nursing confirmed that the usual practice was to store nebulizer masks in drawers, but in reality, this was rarely done, and there was no system in place to ensure compliance. The facility's policy on oxygen administration did not address the need for storing respiratory equipment in protective bags. Additionally, national guidelines reviewed by surveyors indicated that nebulizer parts should be stored in clean, dry plastic bags between uses to prevent contamination, a practice not followed at the facility.
Failure to Notify Responsible Party of New Antibiotic Order
Penalty
Summary
The facility failed to immediately notify a resident's responsible party when a new antibiotic was ordered to treat a urinary tract infection. The resident, an elderly male with severe cognitive impairment, dementia, and an indwelling catheter, was started on Sulfamethoxazole-Trimethoprim for a UTI after a positive urine culture. Review of the medical record and progress notes showed no documentation that the family was informed of the new medication order, despite facility policy requiring notification and documentation of significant changes in condition or treatment. Interviews with the RN who confirmed the order and the DON revealed that the expectation was for nursing staff to notify family members of new medication orders before administration and to document this communication. The RN acknowledged not remembering to notify or document family notification, and the DON confirmed that there was no record of the family being informed. The facility's policy also specified that both the physician and responsible party should be notified and that such notifications should be documented, which was not done in this case.
Failure to Complete Discharge Summaries and Recapitulation of Stay
Penalty
Summary
The facility failed to ensure the completion of discharge summaries, including a recapitulation of the resident's stay and final status at discharge, for three residents reviewed for discharge. For each of these residents, documentation was incomplete or missing, with key sections such as nursing services, physical function status, assistive devices, therapy plans, medication disposition, and skin condition left unaddressed. In some cases, discharge instruction forms were missing essential information such as dietary recommendations, skin condition, patient education, and required signatures. For one resident, the discharge instruction form was dated after the actual discharge date and lacked details in several sections, including dietary, skin, and patient education. The recapitulation of stay form was also incomplete, and no discharge note or summary was found in the medical chart. The family member reported that while medications were sent home, no paperwork or follow-up information was provided at discharge, and the only paperwork received was from a prior hospital stay. For the other two residents, similar deficiencies were observed. One resident's discharge instruction form was incomplete, and the recapitulation of stay document only included vitals and weight, with no comprehensive summary. Interviews with staff revealed that while there was an expectation for discharge summaries and recapitulations to be completed collaboratively by the interdisciplinary team, there was no process in place to ensure that all required information was completed and documented in the medical record. Facility policy required a discharge summary and post-discharge plan to be developed and provided, but this was not consistently done.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
Surveyors identified that the facility failed to provide routine and emergency pharmaceutical services to meet the needs of several residents, specifically in the administration of antibiotics. For three residents reviewed, there were multiple instances where antibiotic medications were either not administered at all or were given outside of the prescribed timeframes. Documentation showed that one resident missed two doses and received 21 doses late, another missed four doses entirely, and a third missed one dose and received several doses late for two different antibiotics. These failures were confirmed through review of medication administration records, physician orders, and care plans. The residents involved had significant medical conditions requiring timely antibiotic therapy, including infections such as Methicillin Susceptible Staphylococcus Aureus (MSSA), infective endocarditis, osteomyelitis, and pneumonia. The care plans for these residents included interventions to administer antibiotics as ordered by the physician, yet the medication administration records revealed consistent lapses in following these orders. In some cases, the antibiotics were not available or not administered as scheduled, and in others, there was confusion or miscommunication regarding the reconciliation of hospital discharge orders and the facility's medication administration process. Interviews with nursing staff, the DON, and other facility leadership revealed that there were established protocols for medication reconciliation, order entry, and administration, including the use of pharmacy automation systems like Pyxis. However, staff interviews indicated issues with communication between hospital discharge paperwork, the facility's EMR, and pharmacy processes. There were also inconsistencies in documentation and notification procedures when medications were missed or administered late, with leadership not being informed of these occurrences as required by facility policy.
Deficient Food Storage, Preparation, and Service Practices
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and service practices. In the walk-in refrigerator, several food items, including lemons, lemonade, lettuce, cucumbers, raw meats, and pureed foods, were found either undated, lacking discard dates, or past their expiration dates. Additionally, some food items were not labeled at all. Flour tortillas were also found with an expiration date approaching, and brown puree was not labeled. These observations were corroborated by staff interviews, which revealed inconsistent practices regarding checking and discarding outdated food. In the kitchen, serving utensils were stored in drawers containing food debris, and the fryer grease was observed to be dirty with visible food particles. Staff interviews indicated varying frequencies for cleaning utensil drawers and changing fryer grease, with some staff stating drawers were cleaned weekly and others after each shift. There was also inconsistency in checking for outdated food, with some staff reporting daily checks and others weekly or twice weekly. The facility's food temperature policy requires all hot food to be served at a minimum of 140 degrees Fahrenheit, but observations showed that food temperatures were not consistently taken before serving, specifically for fried chicken, mixed vegetables, and pureed bread. During meal service, a CNA was observed not sanitizing hands between handling food trays and delivering them to residents' rooms, despite being trained on food safety and infection control. Interviews with other staff confirmed the expectation for hand hygiene between serving trays, but the observed practice did not align with this standard. These combined actions and inactions in food labeling, storage, temperature monitoring, utensil cleanliness, fryer maintenance, and hand hygiene led to the identified deficiency in food service safety.
Failure to Receive and Act on Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen review recommendations from the pharmacy consultant were received and acted upon for one resident. Specifically, the pharmacy consultant sent recommendations regarding medication adjustments for a newly admitted resident, but these recommendations were not received by the Director of Nursing (DON) due to an email delivery failure. As a result, the recommendations were not reviewed or implemented in a timely manner, contrary to the facility's policy requiring monthly pharmacist review and appropriate communication of medication issues to prescribers and facility leadership. The resident involved was an elderly female with multiple complex diagnoses, including traumatic brain injury, fractures, diabetes, cognitive impairment, and other chronic conditions. Her medication regimen included pain management and several other medications. The pharmacist's recommendations included changes to the administration of metformin, consideration of a temporary hold on Lipitor, initiation of calcium/vitamin D supplementation, and a stop order for PRN Norco. These recommendations were not available to the care team or acted upon until the issue was discovered and the recommendations were resent. Interviews with facility leadership confirmed that the process for ensuring receipt and implementation of pharmacy recommendations was not followed as outlined in facility policy. The DON was unaware of who was responsible for verifying receipt of pharmacy communications, and the recommendations for the resident were missing from the pharmacy binder for the relevant month. This lapse resulted in a delay in reviewing and potentially implementing important medication changes for the resident.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance during a transfer, leading to a deficiency in care. A CNA attempted to transfer a resident from a wheelchair to a bed without the required mechanical lift and two-person assistance, as specified in the resident's care plan. The CNA did not see anyone available to assist and decided to proceed alone, resulting in the resident being lowered to the floor when the transfer was unsuccessful. The resident involved was an elderly female with multiple diagnoses, including cognitive communication deficit, pressure ulcer, dysphagia, difficulty walking, repeated falls, and osteoarthritis. Her care plan indicated she required substantial assistance with transfers, specifically a mechanical lift with two-person assistance. Despite this, the CNA attempted the transfer alone, which was against the established protocol and care plan. Interviews with staff revealed that the CNA was aware of the resident's transfer requirements but chose to proceed without assistance due to the absence of other staff in the immediate area. The incident was reported to the nurse, who assessed the resident and found no immediate injuries. However, the resident later complained of arm pain, and an x-ray revealed a humeral fracture. The facility's failure to adhere to the care plan and provide adequate supervision during the transfer led to this deficiency.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, identified as Resident #2, by not ensuring the proper administration of medications. During an observation, a medication aide (MA D) was seen leaving medications with Resident #2 and exiting the room without observing the resident take the medications. This action was contrary to the facility's protocol, which requires staff to supervise residents while they take their medications unless the resident has been assessed and approved to self-administer. Resident #2, who was cognitively intact with a BIMS score of 15, did not have a care plan or assessment for self-administration of medications. Interviews with staff, including the unit manager (UM), assistant director of nursing (ADON), and administrator (ADM), confirmed that the facility's policy mandates supervision of medication administration unless a self-administration assessment is completed and documented in the resident's care plan. MA D admitted to leaving the medication with Resident #2 because the resident did not want to be watched, despite knowing the importance of supervision to prevent potential risks such as choking. The facility's medication administration policy was requested but not provided before the survey exit.
Resident Elopement and Injury Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who was at risk for elopement and falls due to severe cognitive impairment and other health conditions. Despite being assessed as a moderate risk for elopement and a high risk for falls, Resident #1 managed to leave the facility unsupervised. On the day of the incident, she was last seen in the activity room and was later found missing from her room during dinner tray distribution. The staff initiated a search, but Resident #1 was found by a passerby at a gas station approximately one mile away, having sustained a fall resulting in facial injuries. The facility's video footage revealed that Resident #1 exited the building through the front door, following a family member. This incident occurred despite the facility's policy that residents should not leave without proper authorization. Interviews with staff indicated that Resident #1 had not previously exhibited exit-seeking behaviors, and the facility's exit alarms were functioning correctly. However, the staff did not notice her leaving, and there was a delay in realizing she was missing, which contributed to the deficiency. The deficiency was identified as posing a potential risk for falls, injuries, and hospitalization for residents. The facility's failure to adequately supervise Resident #1 and prevent her elopement highlighted a lapse in monitoring and communication among staff. Although the facility had policies and procedures in place for elopement and emergency exits, the incident demonstrated a breakdown in their implementation, leading to Resident #1's unsupervised departure and subsequent injury.
Failure to Ensure Resident Call System Accessibility
Penalty
Summary
The facility failed to ensure the resident call system was accessible to three residents, which could endanger their health or safety if they are unable to call for assistance when needed. Resident #1, an elderly male with multiple diagnoses including pancreatic cancer and diabetes, required maximal assistance for various activities. His call light was found on the floor, and he reported that his calls for help often went unanswered, especially when experiencing frequent diarrhea. He mentioned that he sometimes had to wait up to an hour for assistance, indicating potential staffing issues at the facility. Resident #2, an elderly female with conditions such as deep vein thrombosis and hypertension, also had her call light on the floor. She required extensive assistance with daily activities and was observed needing to get up but unable to reach her call light. Despite a staff member briefly checking on her, the call light remained on the floor, indicating a lack of adherence to the facility's policy of ensuring call lights are within reach. Resident #3, an elderly male with Alzheimer's disease and other health issues, was similarly found with his call light on the floor. He required partial to moderate assistance with daily activities and had mildly impaired cognition. Interviews with staff members revealed that they were aware of the importance of keeping call lights within reach but failed to consistently follow this protocol. The Director of Nursing emphasized the critical nature of accessible call lights for resident safety, yet observations showed this standard was not maintained.
Failure to Maintain Adequate Water Temperature
Penalty
Summary
The facility failed to ensure that residents had access to a safe, clean, comfortable, and homelike environment, specifically by not maintaining resident room water temperatures at a comfortable warm temperature of at least 100 degrees Fahrenheit. This deficiency was observed in the rooms of six residents, who experienced water temperatures significantly below the required threshold, ranging from 76.7 to 90.4 degrees Fahrenheit. These temperatures were recorded during observations and interviews conducted by surveyors on multiple dates in March 2024. Residents reported discomfort and dissatisfaction due to the cold water temperatures. For instance, one resident mentioned that since a freeze in January, the water had been too cold for showers, leading to refusals of baths. Another resident expressed feelings of anger and shame for having to attend a doctor's appointment without a shower due to the cold water. Multiple residents confirmed that the water took a long time to warm up, if at all, and some had to let the water run for extended periods, up to 45 minutes, without achieving a comfortable temperature. Interviews with staff, including CNAs and the Maintenance Supervisor, revealed that the facility had been aware of the issue since a winter freeze in January, which caused a pump failure and subsequent hot water loss in half of the building. Despite attempts to address the problem, the water temperature remained inadequate, particularly in the 300 hall. The Maintenance Supervisor and Administrator acknowledged the ongoing issue and stated that they were working on resolving it, but the problem persisted, affecting the residents' ability to maintain personal hygiene and comfort.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Observations revealed that food items in the dry storage and walk-in freezer were not sealed or dated appropriately. Specifically, a box of fish fillet in the freezer and containers of thick and easy and grits in the dry storage were found opened and undated. Additionally, during lunch service, a cook was observed with improper beard covering, leaving parts of his facial hair exposed. Interviews with the Dietary Manager and the cook confirmed these lapses in food safety protocols. The Dietary Manager was unaware of the undated food items in the freezer and acknowledged that all opened food should be dated and sealed properly. The cook admitted to not fully covering his facial hair, believing it was unnecessary for short stubble. The Lead NSD confirmed that the cook had been instructed multiple times to cover his beard fully but continued to adjust the covering improperly. These failures could place residents at risk for food-borne illness and food contamination.
Infection Control Deficiencies During Catheter and PICC Line Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to several deficiencies in the care of two residents. For Resident #6, LVN E and CNA F did not follow proper infection control procedures during a catheter change. LVN E failed to maintain a sterile field, did not change gloves when necessary, and did not use hand sanitizer between glove changes. CNA F did not change her gloves after performing perineal care, which could lead to cross-contamination. These actions were observed during a catheter change, where supplies were mishandled, and sterile techniques were not followed, increasing the risk of infection for the resident. For Resident #75, RN C and LVN B did not adhere to sterile procedures during a PICC dressing change. RN C failed to maintain a sterile field by using soiled gloves to handle sterile supplies and did not change gloves when visibly soiled with blood. LVN B entered the room without gloves, opened a sterile kit, and handled scissors with bare hands, which could contaminate the PICC line insertion site. These actions were observed during a dressing change, where the insertion site was already compromised by blood, further increasing the risk of infection. Interviews with the involved staff revealed that nerves and the challenging nature of the procedures contributed to the mistakes. The DON and ADON acknowledged the importance of following sterile techniques and hand hygiene to prevent infections. The facility's policies on catheter and PICC line care were not followed, leading to potential cross-contamination and infection risks for the residents involved.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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