Garnet Hill Rehabilitation And Skilled Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Wylie, Texas.
- Location
- 1420 Mccreary Rd, Wylie, Texas 75098
- CMS Provider Number
- 676192
- Inspections on file
- 39
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Garnet Hill Rehabilitation And Skilled Care during CMS and state inspections, most recent first.
A resident with anxiety disorder, paraplegia, and Alzheimer’s disease was receiving trazodone for insomnia, but the facility did not show that a GDR was considered or attempted after the medication was started. The care plan noted the need to review the antidepressant and consider tapering, yet progress notes did not document a GDR review, and a doctor recommendation asking for a trial dose reduction had no documented provider response. The NP said the review was denied because the resident did not want medication changes, while the DON stated GDRs were supposed to be considered every 90 days.
Failure to Provide Toenail Care: A resident with dementia, anxiety, and heart failure had severely overgrown toenails, including both great toenails extending about an inch past the toe and curving to the side. The resident said she had repeatedly asked staff to trim them or arrange podiatry, but no follow-up occurred. Interviews showed nursing and social services staff were aware of the issue and that the resident needed podiatry, while the facility policy stated routine foot and toenail care should be provided within staff scope of practice.
A resident admitted with a suprapubic catheter did not have physician orders in the chart for catheter care, and the April treatment record showed no catheter care orders or documented care. Staff interviews confirmed the resident sometimes performed his own catheter care and sometimes received help, but the LVN could not find any orders, and the DON and ADON stated the orders should have been entered after admission.
A resident with dementia, COPD, heart failure, and hypoxic respiratory failure received IV Invanz through a midline catheter, but the chart lacked physician orders for dressing changes, flushing, and monitoring for infection or infiltration. Staff observed the midline dressing dated several days earlier, and RN, ADON, DON, and NP interviews confirmed the absence of orders and that the dressing should have been changed on a routine schedule.
Failure to Document Review of Pharmacy Recommendations: A resident with anxiety disorder, paraplegia, Alzheimer’s disease, and mild cognitive impairment was receiving trazodone for insomnia and cyclobenzaprine for muscle spasm. The consultant pharmacist recommended a GDR trial for trazodone and review/switching of cyclobenzaprine due to geriatric contraindications, but the record did not show the attending physician documented review of the irregularities or any rationale for no change. Interviews with the ADON, NP, physician, and DON confirmed the recommendations were not clearly documented as acted upon in the chart.
A CNA transferred a resident with muscle weakness using a Hoyer lift without the required assistance of a second staff member, contrary to facility policy and recent training. Interviews and documentation confirmed that only one staff member was present during the transfer, and this practice had occurred on multiple occasions.
Two residents with COPD were not provided with safe respiratory care when their nasal cannulas were left unbagged and improperly stored after use, contrary to facility policy and professional standards. Staff interviews confirmed that the equipment should have been bagged for infection control, and one resident's care plan lacked an intervention for oxygen use despite a physician's order.
A resident with diabetes did not receive a scheduled dose of Farxiga because the medication was not in stock. Staff interviews revealed that the medication aide failed to re-order the medication in a timely manner, and the DON confirmed that the facility's procedures for medication ordering and receiving were not followed, resulting in the resident missing her prescribed medication.
A resident with moderate cognitive impairment and a documented sulfa allergy was given Bactrim, an antibiotic containing sulfa, without prior consent from her medical power of attorney. The allergy was not present in the facility's electronic records at the time, and staff did not notify the representative before administering the medication. The representative discovered the error after the fact, leading to the resident's transfer to the hospital and discontinuation of the medication.
A resident with a documented sulfa allergy was administered Bactrim after the allergy was omitted from the electronic medical record during a system transition. The allergy was not visible to staff or the NP when the medication was ordered and given. The error was discovered after the resident's representative raised concerns, leading to discontinuation of the medication and transfer to the hospital.
A resident's sulfa drug allergy was not transferred into the new electronic medical record system during a manual data migration, resulting in the resident being prescribed and administered Bactrim. The allergy was only discovered after administration, leading to discontinuation of the medication and hospital transfer. Staff interviews confirmed the omission and that the allergy was added to the system after the incident.
The facility failed to maintain privacy and confidentiality for residents during medical treatments and in handling personal health information. Instances included staff not closing doors during treatments and leaving sensitive information unattended, compromising residents' dignity and privacy.
A CNA improperly handled an ice scooper by placing it on top of ice in a bowl, with the handle touching the ice, during drink preparation for residents. This action, observed during lunchtime, violated the facility's infection control policy, which requires the scooper to be placed on a plate beside the ice bowl. The CNA used bare hands, increasing the risk of cross-contamination. Interviews with facility staff confirmed the correct procedure and acknowledged the deficiency.
The facility failed to ensure accurate MDS assessments for two residents, one with an external catheter and oxygen therapy, and another receiving hospice care. The discrepancies between the MDS assessments and the residents' care plans and physician orders were confirmed through observations and interviews with staff. The Administrator acknowledged the importance of accurate assessments to avoid misunderstandings in care provision.
A resident with an overactive bladder using a PureWick external catheter system was at risk of urinary tract infections due to improper storage of the catheter's connecting tube, which was found on the floor. Facility staff, including an LVN, ADON, and DON, acknowledged the oversight and the potential for cross-contamination. The facility's policy on perineal care was reviewed, but the specific policy for external catheter care was not provided.
The facility failed to properly store respiratory equipment for two residents, leading to potential contamination risks. A resident's suction machine and Yankauer were found on the floor, while another resident's nasal cannula was improperly stored, with prongs nearly touching the floor. Staff confirmed the equipment should be bagged and stored correctly to prevent infection, as per facility policy.
A resident with Alzheimer's was sexually assaulted by a visitor at an LTC facility. The facility lacked a visitor tracking system, allowing the visitor to enter and access the resident's room without detection. Staff were not adequately informed or trained on visitor access procedures, contributing to the incident.
A CNA in a LTC facility failed to follow proper incontinent care procedures for a resident with chronic kidney disease and overactive bladder, using the same wipes for different areas, risking cross-contamination and infection. The facility's policy requires a new wipe for each stroke to prevent such risks.
The facility failed to store medications securely for two residents, with a bottle of fish oil found on a resident's recliner and eye drops and Allegra tablets on another resident's overbed table. Both residents had moderate cognitive impairments and no physician orders or assessments for self-administration. Staff interviews revealed a lack of oversight, contrary to the facility's policy requiring medications to be stored properly and accessible only to authorized personnel.
A CNA in a LTC facility failed to follow proper infection control protocols during incontinent care for a resident. The CNA did not perform hand hygiene before putting on gloves, failed to change gloves and sanitize hands appropriately, and hung a new brief on a dirty surface. These actions were contrary to the facility's policies and could lead to cross-contamination and infection.
Failure to Consider GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident receiving psychotropic medication had a gradual dose reduction (GDR) considered and attempted, unless clinically contraindicated. Resident #2 had a BIMS score of 11 and diagnoses including anxiety disorder, paraplegia, and Alzheimer's disease. She was prescribed trazodone 100 mg at bedtime for insomnia starting 07/31/25, and record review showed she received the medication daily as ordered. Her care plan noted a potential for discomfort and side effects related to antidepressant use and stated that a physician should review the medication and that a GDR or tapering may be needed before discontinuation. Record review of progress notes for September 2025, October 2025, and January 2026 did not show that a GDR was attempted or that the medication was reviewed for a GDR. A recommendation for doctor dated 01/16/26 stated that the resident was prescribed trazodone for insomnia since 7/25 and asked the provider to consider a trial dose reduction or document why a GDR was not indicated, but there was no additional document showing a provider response. During interview, the NP stated the GDR review for trazodone was denied because the resident refused medication changes, and the Physician said there was likely not a concern because no changes were made. The DON stated GDRs were considered every 90 days and that failing to consider them timely could leave a resident on a medication long term that might not be good for them. The facility policy stated that within the first year after a psychotropic medication is initiated, GDR attempts are required in two separate quarters with at least one month between attempts unless clinically contraindicated.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care and treatment for one resident, including trimming of toenails, in accordance with professional standards of practice. Resident #83 was a female with diagnoses including non-Alzheimer's dementia, anxiety disorder, and heart failure, and her BIMS score indicated severe cognitive impairment. Her MDS also showed she required substantial to maximal assistance from staff for personal hygiene, and she did not have diabetes. During observation, Resident #83 stated her only concern was her toenails. Both big toenails were observed to be approximately an inch past the tip of the toe and curved to the side, and the other toenails were approximately a quarter of an inch past the tip of the toe. Resident #83 stated she had been asking staff to trim them or to have podiatry come because she did not like seeing them that long. She stated nurses told her they were not able to cut them and that she needed to be seen by podiatry, but no one followed up with her regarding podiatry. Interviews showed CNA B, LVN A, the Social Worker, the ADON, and the DON were aware of the long toenails or the need for podiatry referral. CNA B stated nurses were responsible for trimming residents' fingernails and toenails. LVN A stated she had received report about the resident wanting her toenails trimmed and that the nails were too thick for staff to trim, and she said the resident needed a podiatry referral. The Social Worker stated the resident had last been seen by podiatry about 6 months earlier and that she was not sure why the resident was not being seen by the new podiatrist. The facility's 24 Hour Report/Changes of Condition Report noted the resident needed a podiatry consult/appointment, and the facility policy stated residents would be provided routine foot and toenail care within the professional scope of practice.
Missing catheter care orders for a resident with a suprapubic catheter
Penalty
Summary
The facility failed to ensure a resident with a suprapubic catheter had physician orders for catheter care after admission. Resident #6 was admitted with a suprapubic catheter, had a BIMS score of 15, and his diagnoses included renal insufficiency/renal failure/end-stage renal disease and diabetes mellitus. His care plan identified a urinary catheter problem and included interventions such as assessing for bladder distention, watching for irritation around the catheter, and providing catheter care/changing as ordered, but the April 2026 treatment record and physician orders did not reflect any catheter care orders or care for the catheter. Record review showed the resident arrived with the suprapubic catheter already in place and draining clear urine, with the site described as dry, clean, and intact. The resident stated he had the catheter placed at the hospital and mostly completed his own catheter care, though staff sometimes assisted him. CNA and LVN interviews confirmed he admitted with the catheter and that staff sometimes helped empty the bag or provided care, but the LVN could not find any catheter care orders in the chart. The DON and ADON both stated the resident should have had catheter care orders entered into the chart after admission, and the ADON said she did not review his chart because he was on her side of the building for only one night.
Midline Catheter Dressing and Order Management
Penalty
Summary
Facility staff failed to ensure safe administration of IV fluids for Resident #85, a male resident with diagnoses including non-Alzheimer's dementia, hypertension, acute respiratory failure with hypoxia, COPD, and heart failure. His BIMS score was 07, indicating severe cognitive impairment. He was receiving Invanz 1 GM for a UTI/ESBL, but the physician order did not include directions for changing the PICC/midline dressing, flushing the line, or monitoring for infection and infiltration. During observation, Resident #85 was lying in bed with a midline catheter in his upper left arm, and the dressing was dated 04/12. He stated he was doing well and denied pain or discomfort. RN C later reviewed the orders and confirmed the resident had completed antibiotic therapy, but there were no physician orders for midline dressing changes, flushing, or monitoring for infection. RN C also stated the dressing should be changed every 7 days, but she needed to obtain physician orders first. ADON F stated the expectation was for nurses to obtain physician orders for midline dressing changes, flushing before and after medication, and monitoring for infection, and that if the line was not removed after antibiotics were completed, nurses should still monitor the midline and change the dressing every 7 days. The DON also stated there should be orders for dressing change, flushing, and monitoring, but none were located in the chart. The facility policy for IV therapy required residents receiving infusion therapy to be monitored at established intervals and for staff to check the integrity of the system and dressing.
Failure to Document Review of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that the attending physician documented in Resident #2’s medical record that identified drug irregularities had been reviewed and what action, if any, had been taken. Resident #2’s record showed diagnoses including anxiety disorder, paraplegia, and Alzheimer’s disease, with a BIMS score of 11 indicating mild cognitive impairment. She was receiving trazodone 100 mg daily for insomnia since 07/31/25 and cyclobenzaprine 10 mg daily since 09/25/25, and her quarterly MDS noted she had not completed any GDRs for her medications. The consultant pharmacist issued recommendations regarding both medications. On 09/17/25 and again on 10/21/25, the pharmacist documented that cyclobenzaprine was contraindicated in geriatric patients because of its strong anticholinergic effects and risk for cognitive impairment, weakness, and urinary retention, and recommended considering a different antispasmodic. On 01/16/26, the pharmacist recommended a trial dose reduction for trazodone and asked the provider to indicate if a GDR was not appropriate. The record review found no additional document showing the provider responded to or reviewed these recommendations, and progress notes for September 2025, October 2025, and January 2026 did not reflect that the pharmacy recommendations were acted upon. During interviews, the ADON stated she was responsible for ensuring the pharmacy recommendations were completed and reviewed, but she could not recall or provide proof that Resident #2’s recommendations had been reviewed in the earlier months. The NP and physician stated they received and reviewed the recommendations monthly, but the NP could not recall whether the specific recommendations for Resident #2 had been reviewed and said she reviewed them on the day of interview without making changes because the resident did not want her medications changed. The DON stated the ADONs were responsible for ensuring the recommendations were provided to the providers and followed up on, and that no one else ensured the recommendations were followed up on.
Single-Staff Hoyer Lift Transfer Performed Against Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident using a Hoyer lift without the required assistance of a second staff member. The resident, an elderly female with muscle weakness and incontinence, required extensive assistance with activities of daily living and was cognitively intact. According to the resident's care plan and the facility's policy, two staff members were required to operate the Hoyer lift to ensure safety during transfers. On the day of the incident, the resident was observed in bed with the Hoyer lift still positioned over her, and only one CNA was present in the room. Interviews with the resident and staff confirmed that the transfer was performed by a single CNA, despite the facility's policy and recent in-service training mandating two-person operation of the lift. The CNA involved acknowledged she was unable to find another staff member to assist and proceeded with the transfer alone. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) both confirmed the two-person requirement for Hoyer lift use, and the facility's policy reflected this standard. Documentation and interviews indicated that this practice of single-staff transfers with the Hoyer lift had occurred on multiple occasions.
Failure to Properly Store Oxygen Delivery Equipment for Residents Requiring Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents with chronic obstructive pulmonary disease (COPD) by not ensuring that their oxygen delivery equipment was properly stored when not in use. For one resident, the nasal cannula was observed hanging unbagged on the bedrail after use, despite the resident only requiring oxygen at night and not having used it since early morning. The responsible LVN confirmed that the nasal cannula should have been stored in a bag for infection control, as per facility practice and policy. For the second resident, the nasal cannula was found unbagged on top of the bed while the resident was not present in the room. The ADON acknowledged that the nasal cannula should have been bagged when not in use to prevent infection, and that nursing staff were responsible for ensuring this practice. Additionally, the care plan for this resident did not include an intervention for oxygen use, despite a physician's order for oxygen therapy. The facility's policy required that cannulas be placed in a plastic bag and labeled if oxygen was to be administered on a PRN basis.
Failure to Ensure Timely Re-Ordering and Availability of Diabetes Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with diabetes by not ensuring the availability of a prescribed medication, Farxiga. The resident, who was cognitively intact and required daily Farxiga for diabetes management, did not receive her scheduled dose because the medication was not in stock. Interviews with staff revealed that the medication aide was responsible for re-ordering medications but did not do so in a timely manner, resulting in the medication being unavailable when needed. The LVN and DON confirmed that the medication should have been re-ordered when only a few doses remained, but this process was not followed. Record reviews indicated that the resident's care plan included administering medications as ordered to manage her diabetes and prevent hyperglycemic or hypoglycemic episodes. The facility's policies required staff to order and receive medications according to standard practice guidelines, but these procedures were not adhered to in this instance. The DON acknowledged that the resident's insurance only allowed a 14-day supply of the medication, which required more frequent re-ordering, but staff failed to ensure the medication was ordered and received in time.
Failure to Obtain Consent from Resident's Representative Prior to Administering Contraindicated Medication
Penalty
Summary
The facility failed to ensure that a resident's representative, who held both medical and financial power of attorney, was given the opportunity to exercise the resident's rights regarding consent for new medications. The resident, an elderly female with moderate cognitive impairment and a history of multiple allergies including sulfa, was admitted with diagnoses such as hypertension, UTI, and altered mental status. Despite the resident's cognitive limitations and the presence of a designated representative, the facility administered Bactrim, an antibiotic containing sulfa, without obtaining prior consent from the representative. Documentation showed that the resident's allergy to sulfa drugs was not present in the facility's electronic medical record at the time the medication was ordered and administered. The nurse practitioner prescribed Bactrim for a UTI, and the first dose was given by nursing staff after confirming with the resident, who verbally agreed. However, the representative was not contacted for consent, despite being listed as the medical power of attorney and having a history of being involved in medication decisions. The representative discovered the administration of the medication after the fact and expressed agitation, stating that consent should have been obtained. Interviews with facility staff revealed that the omission of the sulfa allergy in the electronic system was due to a transition in documentation platforms. Staff also indicated that it was standard practice to notify the representative for medication changes, especially given the resident's cognitive status. The nurse practitioner and nursing staff acknowledged that the representative was not contacted prior to administration, and the allergy was only identified after the pharmacy flagged it. The resident was subsequently transferred to the hospital at the representative's request, and the medication was discontinued.
Failure to Update Allergy List Leads to Administration of Contraindicated Medication
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident by not ensuring the resident's allergy list was accurately updated during a transition to a new electronic medical record system. Specifically, the resident had a documented allergy to sulfa drugs, among 37 other allergies, which was omitted when staff manually transcribed information into the new system. As a result, the allergy was not visible to staff or the nurse practitioner (NP) when new medications were ordered. Due to the incomplete allergy documentation, the NP prescribed Bactrim, a sulfa-containing antibiotic, for the resident's urinary tract infection. The medication was administered by nursing staff without knowledge of the sulfa allergy, as the system did not flag the allergy. The resident's responsible representative (RR) became agitated upon learning of the medication administration and expressed concerns about not being consulted prior to the medication being given. The medication was discontinued after the allergy was discovered, and the resident was subsequently transferred to the hospital at the RR's request. Interviews with facility staff, including the administrator, DON, nurses, and the NP, confirmed that the omission of the sulfa allergy was a result of human error during the manual data entry process. The NP stated she would not have ordered Bactrim had the allergy been visible. The incident was documented in the facility's incident log, and hospital records noted the resident's sulfa allergy and subsequent confusion following the administration of Bactrim. The failure to maintain an accurate allergy list directly led to the administration of a contraindicated medication.
Failure to Accurately Transfer Allergy Information During System Change
Penalty
Summary
The facility failed to maintain accurate medical records for a resident during the transition to a new electronic documentation system. Specifically, the resident's allergy to sulfa drugs was not transferred into the new system, despite being listed among 37 allergies on the resident's face sheet. This omission resulted in the allergy not being visible to staff and providers when new medications were ordered. As a result of the missing allergy information, a nurse practitioner prescribed Bactrim, a sulfa-containing antibiotic, for the resident to treat a urinary tract infection. The medication was administered before the error was discovered. The allergy was only identified after the resident's representative notified staff, prompting the discontinuation of the medication and subsequent transfer of the resident to the hospital for evaluation and treatment. Interviews with facility staff, including the administrator, DON, and nursing staff, confirmed that the sulfa allergy was not present in the new system at the time the medication was ordered and administered. The administrator acknowledged the error occurred during the manual transfer of records to the new system and stated that the allergy was added after the incident. No other residents were found to have similar errors during the transition.
Privacy and Confidentiality Breaches in Resident Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as observed in several instances involving four residents. In the first instance, two RNs did not close the door while administering a breathing treatment to a resident with chronic obstructive pulmonary disease. This oversight allowed the treatment to be visible from the hallway, compromising the resident's privacy. The RN acknowledged the mistake, stating that the door should have been closed to ensure the resident's dignity, especially since the resident was non-verbal and unable to express discomfort. In another case, an RN failed to close the door or fully pull the privacy curtain while administering medication through a g-tube to a resident with severe cognitive impairment. This lapse in privacy allowed the procedure to be visible from the hallway. The RN admitted forgetting to close the door or pull the curtain, recognizing the importance of these actions in maintaining the resident's dignity and privacy during medical treatment. Additionally, a medication aide left documents containing personal health information of two residents on top of a medication cart unattended. This occurred in a public area, making the information accessible to unauthorized individuals. The aide acknowledged the error, understanding that the information should have been kept confidential. Interviews with facility staff, including the ADON and DON, confirmed that these actions violated HIPAA regulations and the residents' rights to privacy and confidentiality.
Improper Ice Handling by CNA Leads to Contamination Risk
Penalty
Summary
The facility failed to ensure proper handling of ice to prevent contamination and potential waterborne illness. During lunchtime, a CNA was observed using an ice scooper to prepare drinks for residents. The CNA placed the scooper on top of the ice in the bowl, with the handle touching the ice, instead of placing it on a small plate beside the bowl. This action was repeated multiple times as the CNA prepared drinks for the residents. The CNA used bare hands to handle the scooper, which could lead to cross-contamination from the handle to the ice. Interviews with the ADON, DON, and the Administrator confirmed that the ice scooper should be placed on a plate beside the ice bowl to prevent contamination. The facility's policy on ice storage and sanitary care, revised in August 2018, specifies that ice scoops should be held by the handle and kept in a covered tray when not in use. The CNA acknowledged the mistake and admitted uncertainty about the cleanliness of the tray used to serve drinks. The improper handling of the ice scooper was identified as a deficiency in infection control practices at the facility.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that the assessments for two residents accurately reflected their current medical conditions and care requirements. Resident #20's Quarterly MDS assessment did not indicate the use of an external catheter and oxygen therapy, despite the resident having a diagnosis of overactive bladder and respiratory failure. The resident's care plan and physician orders confirmed the use of a PureWick system and oxygen therapy, which were also observed during an interview with the resident and a Licensed Vocational Nurse (LVN). The LVN confirmed that the resident had been using the PureWick system since admission and was on oxygen therapy for respiratory failure. Similarly, Resident #49's Quarterly MDS assessment failed to reflect that the resident was receiving hospice care, despite the resident's care plan indicating admission to hospice due to cerebrovascular disease. During an observation and interview, it was noted that a suction machine provided by hospice was present in the resident's room. An LVN confirmed that the resident was in hospice care. Interviews with MDS Nurses revealed that the MDS assessments should have included these care details to ensure proper care and interventions were provided. The Administrator acknowledged the importance of accurate MDS assessments in reflecting the residents' current conditions to avoid misunderstandings about the care needed. The facility's policy on resident assessment emphasizes the need for accurate assessments to develop a comprehensive care plan that supports the residents' highest practical level of functioning and well-being. However, the discrepancies in the MDS assessments for Residents #20 and #49 indicate a failure to adhere to this policy, potentially impacting the residents' care and services.
Improper Storage of External Catheter Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. The resident, diagnosed with an overactive bladder, used a PureWick external catheter system every night. However, the facility did not properly store the external catheter, as observed on a specific date when the connecting tube was found on the floor. This improper storage could lead to cross-contamination and increase the risk of urinary tract infections. Interviews with facility staff, including an LVN, ADON, and DON, confirmed that the connecting tube should not be on the floor and should be cleaned and stored properly when not in use. The staff acknowledged the oversight and the potential for germs from the floor to transfer to the catheter, which would have direct contact with the resident's perineal area. The facility's policy on perineal care and incontinence care was reviewed, but the specific policy for external catheter care was not provided during the survey exit.
Improper Storage of Respiratory Equipment for Two Residents
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in the storage and cleanliness of respiratory equipment. Resident #49, a female with severe cognitive impairment and chronic obstructive pulmonary disease, had a suction machine and Yankauer suction tip improperly stored on the floor under her bed. The Yankauer was not bagged, which could lead to contamination. LVN B confirmed that the equipment should not be on the floor and should be kept clean, regardless of its usage status. Similarly, Resident #64, who was diagnosed with shortness of breath and chronic obstructive pulmonary disease, had an oxygen concentrator with a nasal cannula improperly stored. The nasal cannula was hanging on the oxygen concentrator with its prongs nearly touching the floor, posing a risk of contamination. LVN C acknowledged that the nasal cannula should be properly stored even if the resident used it as needed. The nasal cannula was discarded due to potential contamination. Interviews with the ADON, DON, and Hospice Nurse I confirmed that the facility was responsible for maintaining the cleanliness and proper storage of respiratory equipment to prevent cross-contamination and infection. The facility's policy on infection prevention for respiratory therapy tasks emphasized the importance of storing equipment in a plastic bag marked with the date and resident's name, which was not adhered to in these cases.
Failure to Protect Resident from Sexual Abuse by Visitor
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a visitor. The resident, who was cognitively impaired with a diagnosis of Alzheimer's, was sexually assaulted by a visitor she did not know. The incident occurred when the visitor, who was there to see another resident, engaged in inappropriate and non-consensual sexual activities with the resident in her room. The facility did not have a procedure for tracking visitors, which allowed the visitor to enter and move around the facility without detection. The resident's care plan indicated she had severe cognitive impairment and required assistance with daily activities. Despite these needs, the facility did not have adequate measures in place to prevent unauthorized access to residents' rooms or to monitor interactions between residents and visitors. The lack of a visitor log and the posting of the door code outside the facility contributed to the visitor's ability to enter the building and access the resident's room without staff intervention. Interviews with staff revealed that they were not informed of the details of the incident and had not received training on changes to visitor access procedures. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to prevent the incident and the lack of timely reporting and investigation. The facility's inaction and inadequate monitoring placed residents at risk for abuse and emotional distress.
Improper Incontinent Care Leading to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, which could lead to urinary tract infections. During an observation, a CNA was seen using the same wipes to clean both the resident's lower abdomen and perineal area, instead of discarding the wipe after each use. This practice was contrary to the facility's policy, which requires using a different wipe for each stroke to prevent cross-contamination and infection. The resident involved was an elderly female with chronic kidney disease and an overactive bladder, who was frequently incontinent of both bowel and bladder. The CNA acknowledged the mistake during an interview, admitting that the improper technique could cause a urinary tract infection. The facility's policy clearly outlines the correct procedure for perineal care, emphasizing the importance of using a new wipe for each stroke to prevent infection.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications for two residents were stored in locked compartments, as required by regulations. Specifically, a bottle of Nature Made Fish Oil was found on Resident #6's recliner, and Equate Lubricant eye drops and Allegra tablets were found on Resident #7's overbed table. These medications were not stored securely, and there were no physician orders or assessments for self-administration of these medications for either resident. Resident #6, a male with dementia and depressive disorder, was observed with a bottle of fish oil on his recliner. His records showed no physician order for fish oil and no assessment for self-administration of medications. Similarly, Resident #7, a female with anxiety disorder, had eye drops and Allegra tablets on her overbed table without any physician orders or self-administration assessments. Both residents had moderate cognitive impairments, as indicated by their BIMS scores, and neither had care plans for self-medication. Interviews with facility staff, including LVNs, the ADON, the DON, and the Administrator, revealed a lack of awareness and oversight regarding the presence of medications in residents' rooms. Staff acknowledged that medications should not be in residents' rooms to prevent risks such as overdose, accidental ingestion, and choking. The facility's policy mandates that medications be stored properly and accessible only to authorized personnel, which was not adhered to in these instances.
Infection Control Lapses During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during incontinent care for a resident. The CNA did not perform hand hygiene before putting on gloves and failed to change gloves and sanitize hands appropriately during the care process. Specifically, after cleaning the resident's perineal area, the CNA changed gloves without sanitizing hands and did not change gloves after cleaning the resident's bottom before handling a new brief. Additionally, the CNA improperly hung a new brief on the wooden frame of the bed, which was considered a dirty surface, potentially leading to cross-contamination. The CNA acknowledged the failure to follow proper hand hygiene and glove-changing protocols, which could result in cross-contamination and infection. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed the importance of hand hygiene and the need to change gloves when transitioning from dirty to clean tasks. The facility's policies on perineal care and hand hygiene were not adhered to, as staff are expected to perform hand hygiene before and after care, change gloves appropriately, and avoid placing clean items on potentially contaminated surfaces. The failure to follow these protocols was recognized by the facility's administration, who acknowledged the risk of cross-contamination and infection due to these lapses in procedure.
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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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