Cross Timbers Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Flower Mound, Texas.
- Location
- 3315 Cross Timbers Rd, Flower Mound, Texas 75028
- CMS Provider Number
- 675703
- Inspections on file
- 48
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Cross Timbers Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Call lights were not kept within reach for two residents. One resident with stroke, HF, impaired mobility, and a contracted R hand could not find her call light while asking for help removing blankets, and the call light was under her pillow. Another resident with HF, renal insufficiency, neurogenic bladder, urinary retention, and an indwelling catheter said her catheter bag needed emptying, but her call light was tied behind her head and out of reach. Staff and the DON confirmed the call lights were not accessible.
Failure to Provide Toenail Care: A resident with dementia, muscle wasting, HTN, and HF had toenails observed to be overgrown, including big toenails curving to the side. The resident said she could no longer bend over to trim them and no one had asked to do so or arrange podiatry. Staff gave conflicting accounts about who was responsible for nail care, and the SW said podiatry consent was still pending.
Catheter Bag Not Emptied in Timely Manner: A resident with an indwelling catheter, neurogenic bladder, urinary retention, and moderate cognitive impairment was observed in bed with a full urine collection bag. The resident said the bag needed to be emptied and that the call light was out of reach. The assigned LVN was unaware the bag was full, estimated it held 800 cc of urine, and stated it had not been emptied by the overnight shift. The DON stated staff were responsible for emptying catheter bags at least every shift.
Failure to Provide Ordered Oxygen Therapy: Two residents with COPD and oxygen orders were observed without their prescribed oxygen in place. One resident had O2 sats below the ordered threshold and was seen breathing deeply and short of breath without a nasal cannula, while the other resident was repeatedly found in bed with oxygen tubing disconnected or set aside, with an O2 sat of 87%. RN and DON interviews confirmed the oxygen orders were not being consistently followed.
A resident with an immunodeficiency disorder did not receive routine specialized lab monitoring to assess treatment effectiveness. The resident said she had previously seen an infectious disease doctor every 3 months for checkups and labs, but this did not continue after admission. The MD relied on routine bloodwork and clinical assessments, while the DON confirmed there had been no routine specialized labs and could not provide documentation of a referral or discussion of the program.
A resident with cognitive impairment and multiple pressure injuries had wound care debris, including a cup of gauze soaked with betadine, left on the bedside table next to the breakfast tray after treatment. Staff interviews confirmed the wound care trash remained in the room after the treatment nurse and NP completed care, and the DON stated the nurse was responsible for disposing of all treatment items after wound care.
A resident with visual impairment from stroke, Asperger's syndrome, and diabetes requested accommodations for a Kosher-style diet after returning to her religious roots. Although the IDT discussed her religious and dietary restrictions and the Dietary Manager informally adjusted menus to avoid serving dairy and meat together, the comprehensive person-centered care plan did not include any specific, measurable interventions or timeframes addressing these religious dietary needs. The Social Worker reported uncertainty about who was responsible for care plans due to the absence of an MDS Coordinator, and the DON confirmed that no dietary restrictions based on the resident's religious beliefs were documented in the care plan, despite facility policy requiring such needs to be incorporated.
A resident with intact cognition was allowed to keep and self-administer ophthalmic eye drops at bedside without an interdisciplinary team assessment or documented authorization, contrary to facility policy. Nursing staff were unaware of any completed assessment or proper orders, and the resident self-administered the medications without staff oversight.
A resident with dementia and a history of wandering was able to leave the facility unsupervised after repeated exit-seeking behaviors were not properly addressed by staff. Despite the wander guard alarm sounding and staff redirecting the resident twice, the charge nurse did not implement one-to-one supervision or notify administration, allowing the resident to elope and be found by police outside the facility.
The facility failed to ensure proper communication and documentation for two residents requiring dialysis, leading to missing dialysis communication forms for several dates. Both residents, diagnosed with end-stage renal disease, had intact cognition and required hemodialysis. The facility's records showed a lack of adherence to the dialysis protocol, which could result in missed medical orders and recommendations. Interviews revealed that the nursing staff acknowledged the responsibility to collect and file these forms, but the forms were not consistently returned from the dialysis center.
The facility failed to maintain accurate narcotic logs for two residents, leading to discrepancies in medication counts. Additionally, a resident's physician order for Lomotil was delayed due to a failure in processing a faxed order, resulting in a delay in medication administration. Interviews revealed lapses in documentation and auditing expectations, with the facility's policy lacking guidance on narcotic administration records.
The facility failed to act on a pharmacist's recommendations for medication regimen reviews for three residents. One resident's antipsychotic medication was not reviewed by a physician as recommended, and consent forms were improperly handled. Another resident's sleep medication was not reviewed, and a third resident's antidepressant dose reduction was not acted upon. The DON, responsible for these reviews, was on medical leave, leading to unaddressed recommendations.
A resident's medications were found unsecured at their bedside, and insulin vials on two medication carts were not labeled with opening dates, posing risks of overuse and ineffective treatment. The resident had moderate cognitive impairment and was not reassessed for self-administration. Charge nurses acknowledged the oversight, and the ADON admitted to not auditing medication carts regularly.
The facility failed to provide properly textured pureed food during a lunch meal, affecting residents on a pureed diet. A staff member used regular spaghetti instead of egg noodles, resulting in chunky pasta that did not meet the required smooth, pudding-like texture. This oversight was confirmed by state surveyors and the DM, who noted the potential choking risk for residents. The facility did not adhere to its policy of ensuring meals are palatable and safe.
A facility failed to prevent urinary tract infections for a resident with a catheter. The resident's catheter tubing was observed dragging on the floor and was stepped on by the Activity Director, who was unaware of the proper protocol. The resident had severe cognitive impairment and multiple diagnoses. The facility's policy required catheter tubing to be kept off the floor to prevent infections.
A facility failed to monitor a resident's weight upon admission and in the following weeks, leading to undetected weight loss. The resident, with multiple health issues, was not weighed as required by facility policy, resulting in a drop from 127 to 119 pounds. Staff interviews revealed a lack of awareness of the weight management policy, compounded by staffing challenges. The Registered Dietitian and Physician were not informed of the weight loss, preventing timely interventions.
The facility failed to limit PRN orders for antipsychotic drugs to 14 days without evaluation, affecting two residents. One resident received Seroquel beyond 14 days without an end date, while another was inappropriately prescribed Seroquel for sleep despite having dementia. Staff interviews revealed missed responsibilities and a lack of adherence to facility policies on psychotropic medication management.
A resident's call light system was found to be non-functional, leaving her unable to request assistance. The resident, with a history of stroke and other conditions, reported the issue after moving to a new room. The Maintenance Director confirmed the malfunction, noting a possible need for cord replacement.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs and preferences for two residents by not keeping their call lights within reach. Resident #15 had a history of stroke, heart failure, unsteadiness on feet, and lack of coordination, and was dependent on staff for multiple activities of daily living. During observation, she was lying in bed and stated she needed help removing her blankets because she was hot and no one was coming in to help her. When asked to use her call light, she said she did not know where it was; the call light was found underneath her pillow and not within her reach. She only had use of her left hand because her right hand was contracted and she could not move without assistance of her left hand. Resident #65 had diagnoses including heart failure, hypertension, renal insufficiency, neurogenic bladder, urinary retention, and hip fracture, and used an indwelling catheter. During observation, she pointed to her catheter bag and stated it seemed full and needed to be emptied, but no one had come to empty it yet. The catheter bag was observed to be full. When asked to use her call light, she said she would if she knew where it was, and stated she could not reach it because it was located behind her head and tied to the corner of the bed. Staff interviews confirmed the call lights were not positioned within reach. An LVN stated resident call lights should be kept within reach so residents could communicate their needs, and that all staff were responsible for ensuring this. The DON later observed Resident #15's call light underneath two pillows and Resident #65's call light tied to the left corner of the bed behind her head. The facility's policy stated the call light should be accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.
Failure to Provide Toenail Care
Penalty
Summary
Provide appropriate foot care was cited after the facility failed to ensure Resident #8 received proper toenail care. Resident #8 was an [AGE]-year-old female admitted with diagnoses including metabolic encephalopathy, muscle wasting and atrophy, depression, non-Alzheimer's dementia, hypertension, and heart failure. Her BIMS score was 11, indicating moderate cognitive impairment, and her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. During observation, her toenails on both feet were noted to be approximately a quarter of an inch past the tip of the toes, with the big toenails curving to the side. Resident #8 stated she had been cutting her own toenails but had recently been unable to bend over to do so, and she said no one had asked to trim them or arrange podiatry care. Interviews showed inconsistent understanding among staff about who was responsible for toenail care. A CNA stated nurses were responsible for trimming toenails unless the resident was diabetic, while an RN stated that because Resident #8 was not diabetic, CNAs were responsible for trimming her toenails. The RN also observed the toenails and stated they were long and needed to be trimmed by podiatry due to the thickness of the big toenails. The Social Worker stated Resident #8 was not being seen by podiatry and that she was waiting for family to sign a podiatry consent. The ADON and DON stated nurses were responsible for trimming toenails unless the resident was diabetic, and both acknowledged the expectation that toenails be checked and trimmed unless the resident refused. The facility policy stated residents unable to perform ADLs independently are to receive services necessary to maintain good grooming and personal hygiene.
Catheter Bag Not Emptied in Timely Manner
Penalty
Summary
The facility failed to ensure a resident with an indwelling catheter received appropriate care to prevent urinary tract infections when the resident’s catheter urine collection bag was not emptied in a timely manner. Resident #65 was a [AGE]-year-old female with diagnoses including heart failure, hypertension, renal insufficiency, neurogenic bladder, urinary retention, and hip fracture. Her MDS indicated moderate cognitive impairment, dependence on staff for toileting and personal hygiene, and use of an indwelling catheter. Her care plan directed staff to check tubing for kinks, empty the catheter as needed per shift, and monitor and document intake and output, and physician orders included Foley catheter care every shift and Foley catheter output every shift. During observation, Resident #65 was in bed and pointed to her catheter, stating the bag seemed full and needed to be emptied, and that no one had come to empty it yet. The catheter bag was observed to be full of urine, and the resident stated she could not reach her call light because it was behind her head and tied to the corner of the bed. The LVN assigned to the hall stated she was not aware the bag was full and had not been emptied, and estimated the bag contained 800 cc of urine, indicating it had not been emptied by the overnight shift. The DON later stated the aide scheduled for the hall had gone home sick and another CNA was pulled to cover resident needs, and that aides were responsible for ensuring catheter bags were emptied at least every shift.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two residents who had physician orders for oxygen therapy. Resident #59 had diagnoses including COPD with acute exacerbation, respiratory failure, and heart disease, and her physician’s orders required O2 saturation checks every shift and oxygen at 1-5 LPM to keep O2 saturation above 92%. Record review showed O2 saturation readings of 91% on 04/06/26 and 04/08/26, and it was not documented that oxygen therapy was provided when the saturation was outside normal limits. During an observation on 04/15/26, Resident #59 was sitting on the side of the bed, breathing deeply, appearing short of breath, and not wearing her nasal cannula. Her O2 saturation initially measured 85% and then rose to 90% after about one minute. The resident stated she did not wear oxygen continuously and would put it on when she felt she needed it. RN I stated the resident had an order to keep O2 saturation above 92% and that an O2 saturation of 90% indicated she needed oxygen therapy. The DON stated the resident should have been on continuous oxygen therapy to maintain O2 saturation above 92%, but she was not getting enough oxygen because she continued to smoke and had to remove oxygen to do so. The MD stated the resident required continuous oxygen therapy and that the nurses were expected to follow the order as written. Resident #61 had COPD, moderate cognitive impairment, and was ordered continuous oxygen therapy. His care plan reflected oxygen via nasal cannula at 2-6 liters continuous to keep SpO2 above 90%, and the physician’s order required oxygen at 2-6 liters by nasal cannula continuously every shift for shortness of breath. Multiple observations showed the resident in bed without oxygen, with tubing covered by bedsheets or folded and packed in plastic bags. On 04/15/26, RN D observed the resident without oxygen and checked his oxygen saturation at 87%; she stated she knew the oxygen was not on and could not explain why it had not been put back on. She also stated it was the nurses’ responsibility to ensure residents on oxygen were receiving it as ordered. The DON stated it was the charge nurse’s responsibility to ensure physician orders were followed and that Resident #61’s oxygen was always on, and the MD stated he expected the resident to be on oxygen at all times.
Failure to Complete Routine Specialized Lab Monitoring for Immunodeficiency Disorder
Penalty
Summary
The facility failed to provide laboratory services to meet the needs of a resident with an immunodeficiency disorder by not completing routine specialized laboratory monitoring to assess whether treatment remained effective. The deficiency involved one of five residents reviewed for laboratory services. The resident’s record reflected diagnoses including a cerebrovascular accident, hypertension, viral hepatitis, and an immunodeficiency disorder. Her care plan identified impaired immunity, risk for dehydration and increased infections, and included monitoring for abnormal laboratory values and signs of infection. Record review showed laboratory results dated 04/12/26 that included a low WBC, a nonreactive immunodeficiency-related marker, and a CD4 count of 375. The record review also reflected that these immunodeficiency-specific labs were not documented at any other time. The resident’s consolidated physician orders showed routine general health labs were completed as ordered, and a STAT order for CBC, CMP, CD4, and another immunodeficiency-related lab was completed on 04/06/26, but there were no prior orders for these specialized labs to monitor the disorder. During interview, the resident stated she had previously seen an infectious disease doctor every three months for checkups and lab work and was supposed to continue doing so, but had not seen one since admission to the facility. She stated she had spoken to a nurse about it previously but there was no follow-up. The DON stated she was aware the resident had not had routine specialized labs for the disorder and could not provide documentation of a referral or progress note showing discussion of the program. The MD stated he had managed the resident’s disorder but had not ordered routine specialized labs to monitor effectiveness, relying instead on routine blood tests and clinical assessments. The facility policy stated laboratory services were to meet residents’ needs and results were to be reported promptly to the ordering provider.
Wound Care Debris Left on Bedside Table
Penalty
Summary
The facility failed to maintain an infection prevention and control program for Resident #15’s room when wound care trash and debris were left on the resident’s bedside table after treatment. During observation on 04/14/26 at 11:03 a.m., a cup containing used gauze soaked with betadine and other wound care debris was seen next to the resident’s breakfast tray on the bedside table. Resident #15 stated the items were left there by the wound care treatment nurse and the nurse practitioner when they completed treatment on her feet that morning. Resident #15’s record showed she was a [AGE]-year-old female admitted with a BIMS of 10 and diagnoses including stroke, heart failure, unsteadiness on feet, and lack of coordination. Her care plan identified deep tissue pressure injuries to the right lateral foot, left heel, and left lateral foot, with ordered wound treatments including cleansing, Betadine application, and bordered dressings. Staff interviews confirmed the debris remained on the tray table after wound care, and the Treatment Nurse and DON stated the nurse was responsible for disposing of treatment trash and that nothing should have been left on the bedside table.
Failure to Care Plan for Resident’s Religious Dietary Restrictions
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to address a resident's religious dietary needs. The resident was an older female with a history of stroke affecting her vision, Asperger's syndrome, and diabetes, who used a wheelchair and required staff assistance with ADLs. Her quarterly MDS and care plan showed she was PASRR positive, and documentation from an IDT meeting indicated that her Kosher (Jewish) diet had been discussed. However, the care plan dated 12/27/25 contained no specific interventions or measurable goals related to her religious dietary restrictions, despite the facility's policy requiring the IDT, in conjunction with the resident, to develop a comprehensive person-centered care plan describing services to maintain the resident's highest practicable well-being. Interviews further demonstrated the lack of integration of the resident's religious dietary needs into the formal care plan. The resident reported that in the last few months she had begun returning to her religious roots and requested accommodations for a Kosher diet, clarifying she did not expect a Kosher kitchen but wanted her restrictions honored. The Dietary Manager confirmed that the resident had recently decided to follow a "Kosher light" diet, with no dairy on the same plate as meat, and described reviewing the 5‑week menu cycle with the resident to identify acceptable foods and alternatives. The Social Worker stated that care plans were developed through care plan and IDT meetings and that the MDS Coordinator typically created and maintained care plans, but there was currently no MDS Coordinator and she was unsure who was responsible for care plans; she was also unaware of the resident's religious beliefs. The DON acknowledged that although the resident's religious and dietary restrictions were discussed in an IDT meeting, no corresponding interventions were documented in the care plan and agreed there were no specific interventions in place to address the resident's dietary needs, noting that staff could only access the IDT meeting notes.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team determined whether a resident was able to self-administer medications, specifically Systane ophthalmic eyedrops, for one of five residents reviewed for resident rights. The resident, an older adult female with an intact cognition score (BIMS 14), had orders for Systane and Artificial Tears ophthalmic solutions to be kept at bedside for self-administration. However, there was no documented assessment completed to determine if she was clinically appropriate to self-administer these medications, and her baseline care plan indicated she was not able to self-administer any medications. Observations revealed that the resident had both Systane and Artificial Tears eye drops at her bedside and reported self-administering them at bedtime without staff supervision or confirmation. Interviews with nursing staff, including an RN, ADON, LVN, and Medication Aide, showed a lack of awareness regarding whether the resident had been assessed for self-administration or had appropriate orders. Staff assumed the resident was permitted to self-administer based on her alertness and the presence of the medications at bedside, but none could confirm that the required assessment or interdisciplinary team determination had occurred. The facility's policy required that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determined the resident had the decision-making capacity to do so safely. Despite this, the resident was allowed to keep and self-administer eye drops at bedside without the necessary assessment or documented team decision, resulting in a failure to follow established procedures for safe medication administration.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, non-Alzheimer's dementia, non-traumatic brain dysfunction, and Parkinson's disease was not provided with adequate supervision to prevent elopement. The resident had a history of wandering and exit-seeking behaviors, as evidenced by high scores on multiple Wander Data Collection assessments. On the day of the incident, the resident was observed repeatedly attempting to exit through the front door, triggering the wander guard alarm twice. Staff redirected him both times, but did not implement increased supervision or notify facility administration as required by policy. Despite the resident's ongoing agitation and repeated exit-seeking behavior, the charge nurse failed to place the resident on one-to-one supervision or escalate the situation to administration. The resident ultimately left the facility by following others out the front door, with the wander guard system functioning properly. He was found by police down the street and returned to the facility without injury. Staff interviews confirmed that the resident was visibly upset and determined to leave to find his wife, and that staff were aware of his behaviors but did not take additional steps to ensure his safety. The facility's policy required immediate response to door alarms, investigation of the cause, and accounting for residents at risk for elopement. However, these procedures were not fully followed, as the charge nurse did not notify administration or implement one-to-one supervision after multiple exit attempts. The lack of timely intervention and supervision directly led to the resident's elopement from the facility.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation for residents requiring dialysis services, which is a deficiency in maintaining professional standards of practice. Two residents, both diagnosed with end-stage renal disease, were affected by this lapse. The facility did not consistently receive dialysis communication forms from the dialysis center, which are crucial for ensuring continuity of care and monitoring any changes in the residents' conditions. This lack of communication could lead to missed orders and recommendations from the dialysis center. Resident #26, a female with intact cognition, was admitted with a diagnosis of end-stage renal disease and required hemodialysis. Her care plan included goals to prevent complications from dialysis and interventions to monitor for signs of infection. However, the facility's records showed missing dialysis communication forms for several dates in January 2025, indicating a failure to document and follow up on the resident's dialysis treatment. Interviews revealed that the resident was unsure if she returned the forms to the facility, and the nursing staff acknowledged the responsibility to collect and file these forms. Similarly, Resident #245, also with intact cognition and diagnosed with end-stage renal disease, experienced the same issue with missing dialysis communication forms. Her care plan included monitoring for complications and ensuring proper dressing changes at the access site. Despite the facility's protocol requiring communication forms to be completed and returned, the forms were missing for several dialysis dates. Interviews with the nursing staff and administration highlighted a lack of adherence to the facility's dialysis protocol, which could result in the omission of important medical orders and recommendations.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to maintain accurate narcotic logs for two residents on the 200 Hall nurses' medication cart. For one resident, the narcotic administration record for Xanax showed a discrepancy between the recorded and actual pill count. Similarly, for another resident, the narcotic administration record for Tylenol with Codeine also showed a discrepancy. The LVN responsible admitted to administering the medications but failing to sign off on the narcotic administration log, which could lead to potential medication errors. Additionally, the facility did not follow a physician's order for a resident's medication, Lomotil, which was faxed by a hospice nurse. The order was not entered into the system until two days later, resulting in a delay in medication administration. The resident, who had severe cognitive impairment, was reported to have diarrhea, but the anti-diarrhea medication was not administered as ordered. The order was found sitting on top of the fax machine, indicating a failure in the facility's process for handling medication orders. Interviews with facility staff, including the ADON and Corporate RN, revealed expectations for proper documentation and auditing of medication carts, which were not met. The facility's policy on medication administration did not address the narcotic administration record, contributing to the oversight. These deficiencies highlight lapses in the facility's pharmaceutical services, potentially placing residents at risk for medication errors and delays.
Failure to Act on Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's recommendations regarding medication regimen reviews were acted upon for three residents. For one resident, the pharmacist recommended that the antipsychotic medication Quetiapine Fumarate, prescribed as needed for agitation, be reviewed and a new order written every 14 days if extended beyond this period. However, the physician did not review the medication regimen records for October and November, and there was no documentation indicating agreement or disagreement with the pharmacist's recommendation. Another resident was prescribed Quetiapine Fumarate for sleep, and the pharmacist's recommendation for review was not documented as being acted upon by the physician. Interviews with nursing staff revealed that consent forms were not properly completed, and the Director of Nursing (DON) was responsible for ensuring the pharmacist's recommendations were reviewed by the physician. However, the DON was on medical leave, and the necessary forms and reviews were not completed. A third resident was receiving Duloxetine for depression, and the pharmacist recommended a trial dose reduction. This recommendation was not reviewed or acted upon by the physician. The Assistant Director of Nursing (ADON) acknowledged that the DON was responsible for handling pharmacy recommendations, but due to the DON's medical leave, the recommendations were not addressed. The facility's policies require that the pharmacist's findings and recommendations be reported to the DON, attending practitioner, and medical director, but this process was not followed, leading to the deficiencies noted.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the secure storage and proper labeling of medications for one resident and on two medication carts. A resident had several medications, including thymus and thyroid capsules, Advil, and Tylenol, stored unsecured at their bedside. The resident, who had moderate cognitive impairment, was initially assessed for self-administration of medications but had not been reassessed after a decline in cognitive status. The charge nurse acknowledged the oversight and noted that the resident did not have orders for the medications found at the bedside, posing a risk of overuse or adverse reactions. Additionally, the facility did not ensure that insulin vials on two medication carts were labeled with the date they were opened. Insulin pens on the carts for Halls 200 and 300 were found opened and partially used without the required labeling. The charge nurses for these halls admitted to knowing the importance of dating insulin pens but failed to check their carts adequately. This oversight could lead to the administration of expired insulin, which may not be effective. Interviews with the ADON and Corporate RN revealed that it was the responsibility of the nursing staff to ensure medications were not left in residents' rooms and that insulin pens were dated upon opening. The ADON admitted to not auditing the medication carts regularly, which contributed to the deficiencies. The facility's policies on administering and storing medications were not followed, leading to potential risks for the residents.
Failure to Ensure Proper Texture of Pureed Food
Penalty
Summary
The facility failed to provide palatable food during a lunch meal, specifically for residents on a pureed diet. On the observed date, the kitchen staff member, [NAME] F, was responsible for preparing pureed spaghetti pasta. However, the pasta was not pureed to the required smooth, pudding-like texture, as it contained chunks of pasta. This was confirmed during a taste test conducted by three state surveyors and the Dietary Manager (DM), who noted the pasta's chunky texture. The DM acknowledged that [NAME] F used regular spaghetti pasta instead of the usual egg noodle pasta, which is easier to puree, and admitted to not checking the texture of the pureed food items. The facility's failure to ensure the correct texture of pureed food could potentially affect nine residents who were on a pureed diet, as per the facility's records. The facility's Food and Nutrition Services policy requires staff to inspect food trays to ensure meals are palatable, attractive, and served at a safe and appetizing temperature. The DM expressed concern that improperly textured pureed food could pose a choking risk to residents. Despite these requirements, the facility did not adhere to its policy, resulting in the deficiency observed during the survey.
Failure to Prevent Catheter-Associated Urinary Tract Infections
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with a urinary catheter. The deficiency was observed when the resident's catheter tubing was allowed to drag on the floor while she was being pushed in her wheelchair by the Activity Director. The tubing was stepped on by the Activity Director, who was unaware that the tubing should not be on the floor and did not inform anyone to address the issue. This oversight was noted during an observation and was confirmed through interviews with the Activity Director, LVN, and ADON. The resident involved was an elderly female with severe cognitive impairment and multiple diagnoses, including depression, bipolar disorder, and a disorder of the kidney and ureter. The facility's policy on catheter care, revised in January 2023, clearly stated that catheter tubing and drainage bags should be kept off the floor to prevent catheter-associated urinary tract infections. The failure to adhere to this policy posed a risk of introducing bacteria and causing infection, as well as potential physical harm to the resident.
Failure to Monitor Resident's Weight Leads to Unidentified Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by the lack of weight monitoring for a resident upon admission and in the subsequent weeks. Resident #68, an elderly female with multiple diagnoses including depression, bipolar disorder, dorsalgia, kidney disorder, cognitive impairment, and malnutrition, was admitted without an initial weight being recorded. The facility's policy required new admissions to be weighed weekly for the first four weeks to establish baseline weights, but this was not done for Resident #68, resulting in her weight loss going unnoticed. The resident's weight was recorded at 127 pounds in her hospital records prior to admission, but subsequent facility records showed a decrease to 119 pounds within a few weeks. Despite the resident's meal intake records indicating she was eating a significant portion of her meals, the weight loss was not identified or addressed. Interviews with staff revealed a lack of awareness and adherence to the facility's weight management policy, with the ADON unaware of the requirement for weekly weights and the Registered Dietitian noting the absence of a recorded weight in the system. The oversight was compounded by staffing challenges, including an ice storm and the DON being on medical leave, which may have contributed to the missed weight checks. The Registered Dietitian and Physician both indicated that had they been informed of the weight loss, they would have implemented measures to address it. However, due to the failure to monitor the resident's weight as per policy, these interventions were not initiated, placing the resident at risk for further nutritional decline.
Failure to Limit PRN Antipsychotic Orders and Inappropriate Use for Sleep
Penalty
Summary
The facility failed to ensure that PRN orders for antipsychotic drugs were limited to 14 days and could not be renewed without an evaluation by the attending physician or prescribing practitioner. This deficiency was identified for two residents who were reviewed for unnecessary medications. Resident #35 had a PRN order for Seroquel, an antipsychotic medication, which extended beyond 14 days without an identified end date. The resident, who had a diagnosis of post-traumatic stress disorder and moderate cognitive impairment, received the medication on multiple occasions without the required evaluation. The ADON acknowledged the oversight and stated that the responsibility to follow up on such orders was missed. Resident #44, who had severe cognitive impairment and a diagnosis of unspecified dementia, was receiving Seroquel for sleep, which is not an appropriate use of the medication. The care plan for this resident indicated a goal to reduce the use of psychotropic medication, yet the resident was prescribed Seroquel for sleep. The MDS Coordinator and the ADON both acknowledged that the resident should not have been on this medication for sleep, and the Corporate RN noted that alternative medications should have been considered. The facility's policies on psychotropic medication management were not followed, as PRN antipsychotic medications should be re-evaluated every 14 days, and Seroquel is not approved for the treatment of dementia-related psychosis. The failure to adhere to these policies placed residents at risk for receiving unnecessary medications and potential adverse drug reactions. Interviews with facility staff revealed a lack of awareness and oversight regarding the appropriate use and monitoring of antipsychotic medications.
Resident Call Light System Malfunction
Penalty
Summary
The facility failed to ensure that a resident's room was equipped with a functioning call light system, which is essential for residents to request assistance from staff. This deficiency was identified during an observation and interview with a resident who had recently been moved to a new room. The resident, who had a history of stroke, depression, bipolar disorder, and obstructive sleep apnea, reported that her call light was not working when she attempted to use it to request assistance. Upon testing the call light, it was confirmed that it did not activate, indicating a malfunction. The Maintenance Director was unaware of the issue until it was brought to his attention during the interview. He confirmed the malfunction after testing the call light himself and noted that the cord might need replacement. The facility's policy requires that the resident call system remains functional at all times, but this was not adhered to in this instance, potentially leaving the resident without a means to call for help when needed.
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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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