Renaissance Park Multi Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 4252 Bryant Irvin Rd, Fort Worth, Texas 76109
- CMS Provider Number
- 455891
- Inspections on file
- 41
- Latest survey
- July 16, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Renaissance Park Multi Care Center during CMS and state inspections, most recent first.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with a primary diagnosis of sickle cell pain crisis and a complex medical history did not have a care plan addressing her condition, including no interventions or goals for sickle cell disease management. Staff interviews revealed a lack of awareness and training regarding the disease, and there was no evidence of regular monitoring of hemoglobin levels. The deficiency became apparent when the resident was hospitalized for heart palpitations and critically low hemoglobin, highlighting the facility's failure to follow its own care planning policies.
A resident with burn injuries did not receive Aquaphor ointment to both thighs as ordered by her physician, with staff failing to consistently apply the treatment and follow wound care instructions. The resident reported not receiving the prescribed care for two weeks, and staff interviews revealed confusion and lapses in treatment administration and order transcription.
Two residents were provided bed rails or grab bars without proper assessment, documentation, or informed consent. For one resident with moderate cognitive impairment and a history of falls, grab bars were installed after a fall, but there was no physician's order, side rail assessment, or care plan addressing their use. Another resident with severe cognitive impairment and mobility needs had grab bars in use despite no documented assessment or consent. Staff interviews and record reviews confirmed that required procedures for bed rail use, as outlined in facility policy, were not followed.
The facility did not accurately transcribe and implement physician orders for two residents with complex medical needs. One resident's chart omitted several admitting diagnoses and lacked orders for necessary lab monitoring, while another resident's wound care orders from an outside specialist were not fully transcribed, resulting in incomplete care. Staff interviews confirmed gaps in awareness and documentation, and facility policy for order entry was not followed.
A resident's next-of-kin was unable to obtain the resident's medical records despite multiple formal requests and submission of required documentation. The request was delayed for over two months due to miscommunication and lack of follow-through between the facility and its legal department, resulting in non-compliance with regulations requiring timely release of records.
A resident with a history of serious medical conditions developed a stage 3 pressure ulcer due to the facility's failure to implement preventive measures and conduct thorough skin assessments. Despite having a care plan, the resident's refusals of care were not documented, and assessments were incomplete, leading to hospitalization and a diagnosis of sepsis. The facility's inadequate documentation and reliance on the resident's self-reports contributed to the oversight.
The facility did not ensure the Dietary Manager wore a beard restraint in the kitchen, contrary to professional standards for food service safety. The Dietary Manager was observed without a beard restraint, claiming it was only required when cooking. The facility's policy requires all dietary staff to wear hair restraints to prevent food contamination. The Administrator confirmed the expectation for compliance with the uniform policy.
A facility failed to ensure safe and sanitary storage of food in a resident's personal refrigerator. The resident's fridge contained a buildup of ice with grapes and a paper towel, and the resident reported it was not cleaned by staff. Interviews revealed confusion over responsibilities for fridge maintenance, contrary to facility policy requiring regular checks and discarding of expired or contaminated food.
A resident receiving enteral nutrition did not receive appropriate care when RN R failed to check g-tube placement and used a syringe and plunger instead of the gravity method to administer medication. The resident, with a history of multiple medical conditions, had specific care plan instructions for tube feeding that were not followed. The DON confirmed the correct method was not used, as per facility procedures.
The facility failed to maintain infection control measures, as a nurse did not change gloves or perform hand hygiene during wound care for a resident with a heel injury, and a visitor did not follow PPE protocols during a COVID-19 outbreak. Despite training, these lapses were acknowledged by the ADON and DON, highlighting risks of infection transmission.
A medication error occurred in an LTC facility when a medication aide mistakenly administered medications intended for one resident to another, including a narcotic. The error was discovered when the second resident refused the medications, leading to the realization that the first resident had received the wrong medications. The affected resident required Narcan to reverse the effects of the opioid, highlighting a lapse in verifying resident identity and medication rights.
A medication error occurred when a resident received another's medications, including a narcotic, leading to lethargy and confusion. Narcan was administered, but the facility failed to report the incident to authorities, as they did not consider it reportable due to no perceived harm.
A contracted LVN failed to follow proper infection control procedures during wound care for a resident with severe cognitive impairment and multiple medical conditions. The LVN did not change gloves or perform hand hygiene, reused gauze, and placed soiled items on the bed, risking cross-contamination. Despite being offered assistance, the LVN conducted the procedure alone, causing discomfort to the resident and concern from the family. The facility's DON and ADM acknowledged the breach in infection control policy.
The facility failed to maintain a safe environment in the dining room and employee restroom. Observations revealed drooping, sagging, and bubbled paint on the dining room walls and stained ceiling tiles due to a leak. An unidentified black substance was found in the dietary department's employee restroom, which was reportedly treated but still present. The Maintenance Director acknowledged the issues, citing a leaking air conditioner as the cause, and noted that the damage existed before his employment.
A long-term care facility failed to maintain an effective pest control program, resulting in a persistent issue with gnats and horseflies affecting multiple residents and areas. Despite regular visits from a pest control company, residents reported being bitten by horseflies, and staff confirmed the ongoing problem. The facility lacked a dedicated Maintenance Director, relying on temporary measures to manage the situation, while the Administrator suspected a drain issue and leftover food as contributing factors.
The facility failed to ensure the Activities Director (AD) was a qualified professional, as the AD was not licensed or registered by the state. The AD had been working for two weeks and was in the process of completing a certification course. Despite conducting activities without resident complaints, the facility's job description required the AD to be licensed or registered. This oversight could affect the quality of life for residents due to a lack of individualized activities.
A resident with severe cognitive impairment was sent to the ER for a clavicle fracture, but the LTC facility failed to document the transfer and communicate with the hospital for discharge paperwork and new care orders. Communication breakdowns among staff, including LVNs and the liaison, led to the resident returning without necessary documentation, putting the resident at risk.
A CNA in an LTC facility failed to perform proper hand hygiene before providing ADL care to a resident with metabolic encephalopathy. The CNA entered the resident's room wearing gloves, touched various surfaces, and repositioned the resident without sanitizing hands, contrary to infection control protocols. Interviews revealed a lack of understanding of infection control practices, with the CNA placing gloves in her pocket, believing they remained clean. Facility staff confirmed the risk of cross-contamination and emphasized the need for proper hand hygiene and glove use.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Develop and Implement Comprehensive Care Plan for Sickle Cell Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a primary diagnosis of sickle cell pain crisis. Despite the resident's complex medical history, including sickle cell/HB-C disease with crisis, alcoholic cirrhosis, aseptic necrosis of bone, multiple fractures, anemia, and end stage renal disease, the baseline care plan did not include any focus, interventions, or goals related to sickle cell disease or its management. The resident's medical records indicated a history of low hemoglobin levels and multiple blood transfusions, yet there was no evidence of ongoing assessment or care planning for these issues. Interviews with facility staff revealed a lack of awareness and training regarding the specific needs and symptoms associated with sickle cell disease. Nursing staff were not aware of any orders for regular monitoring of the resident's hemoglobin levels, and there was confusion about the process for obtaining and reviewing lab results. The facility's Regional Compliance Nurse and ADON acknowledged the importance of monitoring lab values and care planning for serious conditions but confirmed that these steps were not taken for this resident. The deficiency was further highlighted when the resident experienced heart palpitations and was transported to the emergency room by family, where a critically low hemoglobin level was discovered, resulting in hospital admission. The facility's own policies required individualized care plans based on comprehensive assessments, but these were not followed, placing the resident at risk for not receiving proper care and services due to inaccurate or incomplete care planning.
Failure to Provide Burn Treatment as Ordered
Penalty
Summary
A deficiency was identified when a resident with significant burn injuries to both thighs did not receive treatment as ordered by her physician. The resident's care plan included interventions for impaired skin integrity, specifically requiring the application of Aquaphor ointment to both thighs twice daily to prevent dryness and promote healing. Physician instructions also included daily gentle washing of the lower extremities and moisturizing the wounds twice a day. However, review of the Treatment Administration Record (TAR) and interviews revealed inconsistencies and lapses in the administration of the prescribed treatment. During observation and interviews, the resident reported that staff had not been applying the Aquaphor treatment as ordered for two weeks, resulting in dry, itchy, and peeling skin on her thighs. The resident showed the surveyor her burns, which appeared dry and lacked the expected moisturized appearance. Staff interviews revealed confusion regarding the application process, with one RN admitting to being distracted and not completing the treatment, and the ADON stating she applied the ointment only after being asked by another nurse. The resident also noted that the area was not washed prior to application, contrary to the specialist's instructions. Further interviews with facility staff, including the Regional Compliance Nurse and the Administrator, confirmed that there were gaps in the transcription and monitoring of physician orders, leading to the resident not receiving care as prescribed. The facility's policy on documentation of new or changed physician orders did not address the need to follow physician orders, contributing to the failure to provide appropriate treatment and care according to the resident's needs and medical directives.
Failure to Assess, Document, and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess, document, and obtain informed consent for the use of bed rails and grab bars for two residents. For one resident with a history of stroke, dysphagia, and moderate cognitive impairment, grab bars were installed after a fall at the request of the resident and family. However, there was no evidence of a physician's order, a completed side rail assessment, informed consent, or a care plan addressing the use of bed rails or grab bars for mobility. The resident's care plan only addressed fall risk with interventions such as floor mats and a high back wheelchair, but did not mention bed rails or grab bars. For another resident with severe cognitive impairment, pressure ulcer, and significant mobility needs, grab bars were observed in use despite the comprehensive assessment indicating no bed rail use. While there was a physician's order for quarter side rails to enable bed mobility, there was no documented side rail assessment, informed consent, or care plan addressing the use of bed rails or grab bars for mobility. The care plan focused on combative behavior and risk of injury during care, but did not include interventions related to bed rails or grab bars. Interviews with nursing staff and administration revealed a lack of awareness and inconsistent practices regarding the assessment, documentation, and consent process for bed rail use. The facility's policy required assessment, physician's order, informed consent, and care plan development for bed rail use, but these steps were not followed for the two residents. The absence of these required processes was confirmed through record review, staff interviews, and direct observation.
Failure to Accurately Transcribe and Implement Physician Orders for Two Residents
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents, specifically in the transcription of admitting diagnoses and physician orders. For one resident with a complex medical history including sickle cell disease with crisis, alcoholic cirrhosis, multiple fractures, anemia, and end stage renal disease, the face sheet and order summary did not accurately reflect all admitting diagnoses. The paper chart listed only sickle cell pain crisis as the admitting diagnosis, omitting other significant conditions. Additionally, there were no physician orders for monitoring hemoglobin levels or routine lab work, despite the resident's high risk for complications due to her medical conditions. Interviews with nursing staff revealed a lack of awareness regarding orders for lab monitoring, and the baseline care plan did not address the resident's sickle cell disease with crisis. For another resident admitted with extensive third-degree burns and other diagnoses, the facility failed to transcribe and implement wound care orders as provided by an outpatient surgical specialist. The specialist's instructions included daily bathing and gentle washing of the lower extremities before moisturizing, but the facility's orders only specified the application of Aquaphor ointment to the thighs twice daily, omitting the washing step. Interviews with the resident and staff confirmed that the skin was not washed prior to ointment application, and staff were unaware of the full wound care instructions. The care plan referenced treatment as ordered but did not specify the complete wound care regimen. Facility policy required that new or changed physician orders be entered promptly and completely, including all directions and administration details. However, interviews with the ADON, Regional Compliance Nurse, and ADM revealed that orders from outside providers were not always reviewed or transcribed accurately into the residents' charts. This led to discrepancies between the care provided and the prescribed treatment, as well as incomplete documentation of residents' medical conditions and care needs.
Failure to Timely Provide Medical Records to Next-of-Kin After Resident Death
Penalty
Summary
The facility failed to provide a resident's next-of-kin with copies of the resident's medical records after a formal request was submitted. The resident, a male who was his own responsible party, was found unresponsive and later pronounced dead. Following his death, the next-of-kin, listed as Emergency Contact #2, attempted to obtain the resident's medical records. The next-of-kin initially tried to have the person with Medical and Durable Power of Attorney request the records, but was informed that the power of attorney was no longer valid after the resident's death. The next-of-kin then submitted the request directly, providing documentation such as a death certificate, driver's license, and birth certificate to establish kinship. Despite multiple written and email requests, including submission of an Authorization for Release of Medical Information and supporting documents, the next-of-kin did not receive the records for over two months. The facility's Director of Medical Records (DMR) stated that requests are typically processed within 30 days and that she normally ensures timely completion. However, in this case, the request was forwarded to the facility's legal department, and due to a change in legal personnel, the request was not fulfilled. The DMR and Administrator later discovered that the attorney handling the request was no longer with the company, and the new attorney was unaware of the pending request. Throughout the process, the next-of-kin repeatedly contacted the facility for updates and clarification, referencing regulatory requirements for timely release of records. The facility's policy and federal regulations require that such requests be fulfilled within 30 days, and the DMR acknowledged that the next-of-kin, as the resident's personal representative, was entitled to the records. The failure to provide the records in a timely manner was attributed to a lack of communication and follow-through between the facility and its legal department.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to the development of a stage 3 pressure injury. The resident, who had a history of malignant neoplasm of the colon, systemic lupus erythematosus, Parkinson's disease, and neuralgia, was admitted to the facility with intact cognition and was at risk for pressure ulcers. Despite having a care plan that included interventions such as pressure-reducing devices and weekly skin checks, the facility did not implement these measures effectively. The resident's skin assessments were incomplete, and refusals of skin assessments were not documented, resulting in the failure to identify a stage 3 pressure ulcer on the resident's sacrum, which was later discovered at the hospital. The resident was transferred to the hospital after being found lethargic and requiring extensive assistance, where she was diagnosed with sepsis due to a methicillin-resistant Staphylococcus aureus infection, acute renal failure, and a stage 3 pressure injury. Interviews with facility staff revealed that the resident was independent and often refused assistance, which contributed to the lack of thorough skin assessments. The facility's documentation practices were inadequate, as the resident's refusals were not properly recorded, and skin assessments were based on the resident's self-reports rather than actual examinations. The facility's failure to conduct thorough skin assessments and document refusals led to the resident's condition worsening, resulting in hospitalization and subsequent death. The Director of Nursing acknowledged the importance of skin assessments and the risks associated with neglecting them, but the facility's practices did not align with these standards. The lack of consistent and accurate documentation, combined with the resident's modesty and refusal of care, contributed to the oversight and eventual identification of the pressure ulcer at the hospital.
Removal Plan
- Identified resident no longer resides in the facility
- Education will be completed regarding conducting thorough skin assessments, Braden assessments, updating care plans, documenting of refusal of resident care, and implementing resident specific interventions related to pressure ulcers. This education will be provided to all licensed nursing staff by the Director of Nurses or Regional Nurse Consultant.
- Infection Prevention Nurse, Director of Nurses, Staff nurse and Regional Nurse conducted a skin sweep on all residents in the facility
- All residents that reside in the facility will have a completed skin data collection tool, Braden and updated care plan by the Infection Nurse, Director of Nurse, Staff nurse or Regional Nurse
- The DON and IP nurse and Regional Nurse began immediate in servicing of current licensed nursing staff on the following: Completion of a thorough skin assessment upon admission within 24 hours by charge nurse weekly
- Completion of Braden assessment upon admission and then weekly X4 weeks and then monthly.
- Completion of care plan upon admission and updated on any significant change
- Completion of implementation of interventions upon identifying any wound areas
- How to Document refusal of skin assessments by residents, notifying DON of any skin assessment refusals immediately
- Current licensed staff will not be allowed to work until completion of education as noted above
- Director of Nurses, Infection Nurse and Regional Nurse will complete the following until substantial compliance has been achieved and maintained: Review and documented audits for completion of weekly skin assessments for residents
- Review and documented audits for completion of refusal skin sheets
- Review and documented audits for completion of Braden assessments audits
- Review and documented audits for care plans for residents with pressure ulcers identified
- Review and documented audits for interventions for residents with pressure ulcers identified
- The facility will continue to provide on-going in-services as noted above to newly hired licensed nursing staff, annually and as needed.
- All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved.
Dietary Manager Fails to Wear Beard Restraint in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that the Dietary Manager wore a beard restraint while in the kitchen. During an observation and interview, it was noted that the Dietary Manager was not wearing a beard restraint as he walked through the kitchen. He justified his action by stating that a beard restraint was only necessary when cooking food, although he acknowledged that hair could contaminate food if restraints were not worn. The facility's policy, as reviewed, mandates that all dietary staff, including those with facial hair, must wear hair restraints to prevent hair from contacting food. The Administrator confirmed that the expectation was for all employees to follow the uniform policy, which includes wearing hair restraints to avoid food contamination.
Failure to Maintain Safe and Sanitary Storage in Resident's Personal Refrigerator
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of food items in a resident's personal refrigerator. Specifically, Resident #23's refrigerator was not cleaned, and items were not discarded according to the facility's policy. During an observation and interview, it was noted that the refrigerator contained protein shakes, yogurt cups, and an ice tray with a buildup of ice that included grapes and a paper towel. Resident #23, who has intact cognition, reported that staff did not clean her fridge. Interviews with facility staff revealed inconsistencies in the responsibilities for maintaining the cleanliness of residents' personal refrigerators. A CNA stated that CNAs were responsible for checking the refrigerators and their temperatures, while the Administrator indicated that housekeeping was responsible for cleaning them. The facility's policy requires staff to check for expired food, label and date food items, and discard any suspected contaminated food. The failure to adhere to these procedures could compromise infection control and potentially make residents sick.
Improper Administration of Medication via G-tube
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications. Specifically, RN R did not check the placement of the g-tube before administering medication to a resident. Instead of using the gravity method, RN R used a syringe and plunger to push medication and water directly into the g-tube. This method is contrary to the facility's procedure, which requires allowing medication to flow by gravity to prevent complications. The resident involved was an elderly female with a history of a type 2 dens fracture, type 2 diabetes, chronic kidney disease, and acute cholecystitis. The resident's care plan included specific instructions for tube feeding, including verifying the position of the enteral access device. Despite these instructions, RN R did not follow the correct procedure, which was confirmed by the Director of Nursing, who stated that the gravity method should always be used to administer medication via g-tube. The facility's procedure guide also emphasized the importance of confirming feeding tube placement and using gravity to administer medications.
Infection Control Deficiencies in Wound Care and Visitor Protocols
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by two specific incidents involving residents. In the first incident, a registered nurse (RN R) did not adhere to hand hygiene protocols while providing wound care to a resident with a right heel deep tissue injury. The RN did not change gloves or perform hand hygiene after removing a soiled dressing, which was acknowledged by both the RN and the Assistant Director of Nursing (ADON) as a risk for infection transmission. Despite monthly in-services on infection control and hand hygiene, the RN admitted to using only one pair of gloves during the procedure. In the second incident, a visitor for another resident did not follow the facility's infection control policy during a COVID-19 outbreak. The visitor entered and exited the resident's room without using hand sanitizer or wearing the required personal protective equipment (PPE), despite clear signage indicating droplet and contact precautions. The ADON and Director of Nursing (DON) acknowledged the lapse in enforcing PPE use among visitors, noting that while staff were required to wear gowns, masks, eye protection, and gloves, visitors were only encouraged to do so. The DON stated that the visitor should not have left the room to fill a water pitcher, as this posed a risk of infection transmission.
Medication Error Involving Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by an incident involving two residents. A medication aide, identified as MA D, mistakenly administered medications intended for one resident to another. This error occurred because MA D was unfamiliar with the residents and their bed arrangements, having only worked at the facility for four days. The error was discovered when the resident who received the wrong medications, including a narcotic, became lethargic and required medical intervention with Narcan to reverse the effects of the opioid. The resident who received the incorrect medications had a history of repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. At the time of the incident, he was cognitively intact with a BIMS score of 15 and required assistance with various activities of daily living. The medications he was supposed to receive were held, and he was mistakenly given medications intended for another resident, who had a different set of medical conditions and required different medications, including oxycodone for pain management. The error was identified when the second resident refused the medications, recognizing that they were not his. This prompted the staff to realize the mistake, leading to an immediate response to assess and treat the affected resident. The incident highlighted a lapse in the medication administration process, particularly in verifying resident identity and medication rights, which could have led to severe medical complications for the resident involved.
Medication Error and Reporting Failure
Penalty
Summary
The facility failed to report an incident of possible neglect to Health and Human Services involving a significant medication error. A medication aide administered the morning medications of one resident to another, including a narcotic and a psychoactive medication. This error was not reported to the state agency, which could place residents at risk of being neglected and lacking oversight by a state agency. The incident involved two residents with complex medical histories. The first resident, who received the incorrect medications, was a male with diagnoses including repeated falls, anxiety disorder, chronic kidney disease, diabetes, and heart disease. He had intact cognition and required assistance with various activities of daily living. The second resident, whose medications were mistakenly given to the first, had a history of metabolic encephalopathy, acute respiratory failure, type 2 diabetes, and other serious conditions. He was moderately cognitively impaired and dependent on staff for most activities of daily living. The error occurred when the medication aide, while in the process of administering medications to the second resident, switched to the first resident due to a therapist waiting to take him to therapy. The aide inadvertently switched the medication cups, leading to the administration of the wrong medications. The first resident became lethargic and confused, prompting the administration of Narcan due to the stronger dose of oxycodone he received. Despite the immediate response, the facility did not initially report the incident as they did not consider it reportable, believing there was no harm to the resident.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during wound care for a resident. LVN A did not change gloves or perform hand hygiene while providing wound care, which is a critical step in preventing the spread of infection. During the procedure, LVN A reused the same gauze to clean the wound multiple times and placed soiled items on the bed next to the resident, further increasing the risk of cross-contamination. The resident involved was an elderly female with a history of severe cognitive impairment and multiple medical conditions, including a stroke, fractures, and sepsis. She required assistance with bed mobility and had an active order for wound care on her sacrum. Despite these needs, LVN A conducted the wound care without assistance, which compromised the resident's safety and comfort. The resident expressed discomfort during the procedure, and her family questioned the appropriateness of the care being provided. Interviews with staff revealed that LVN A was a contracted nurse from an agency and not a regular employee of the facility. Despite being offered assistance by another LVN, LVN A chose to perform the wound care alone, which he later admitted was a mistake. The corporate DON and the facility's ADM both expressed that LVN A's actions were not in line with the facility's infection control policies, and the DON stated that LVN A would not be allowed to return to the facility.
Facility Fails to Maintain Safe Environment in Dining Room and Restroom
Penalty
Summary
The facility failed to maintain a safe environment in the dining room and employee restroom, as observed by surveyors. The dining room outside the dietary department had walls with drooping, sagging, and bubbled paint, and the ceiling tiles above were stained brown due to a leak. Additionally, the dietary department's employee restroom had an unidentified black substance on the ceiling and door facing, which was reportedly treated by the Maintenance Director. However, the black substance was still present during the surveyor's observation. Interviews revealed that the Maintenance Director, who had been employed for one month, was aware of the issues and had treated the area with mold spray. The Maintenance Director mentioned that the air conditioner had been leaking, causing moisture and damage to the wall, which existed before his employment. The Maintenance Repair Log indicated an entry about the AC leaking in the dining room, requesting repair by the Administrator. The facility's policy on Preventative Maintenance Services emphasized the need for timely maintenance to protect the health and safety of residents, personnel, and the public.
Inadequate Pest Control Program Leads to Insect Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent issue with gnats and horseflies in one of the hallways and several residents' rooms. Observations and interviews revealed that residents had been dealing with insect problems for weeks, with some residents reporting being bitten by horseflies, which caused them pain. The presence of insects was noted in the rooms of four residents, with visible gnats and horseflies observed during the survey. The facility's pest control logs indicated regular visits from a pest control company, but the problem persisted. Interviews with staff, including the RN, ADON, and DON, confirmed that the insect issue had been ongoing for several months, with residents frequently complaining about the problem. The facility lacked a dedicated Maintenance Director, relying instead on a Maintenance Director from a sister facility. Despite the pest control company's bi-weekly visits, the insect problem remained unresolved, with staff using temporary measures like electronic bug zappers to manage the situation. The DON and Administrator acknowledged the potential infection control risks posed by the insects, especially for residents with IV lines, wounds, and colostomy bags. The Administrator believed the insects might be entering through a drain and had plumbers working on the issue. Additionally, leftover food in residents' rooms was identified as a potential attractant for flies. The facility's pest control policy required frequent treatment to ensure a pest-free environment, but the ongoing insect problem indicated a failure to adhere to this policy effectively. The Administrator stated that only one resident had formally complained, and they were moved to another room, but the issue was more widespread, affecting multiple residents and areas within the facility.
Unqualified Activities Director in LTC Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional. The Activities Director (AD) had been working in the role for two weeks without being licensed or registered as required by state regulations. The AD was in the process of completing a certification course, which was four weeks long, and had one week remaining before taking the certification exam. Despite conducting various activities such as bingo, word searches, and music, the AD was not yet qualified according to the facility's job description, which mandates that the AD must be a qualified activities professional licensed or registered by the state. Interviews with the Director of Nursing (DON) and the Administrator revealed that the AD had been conducting activities without any complaints from residents. However, the Administrator acknowledged that it was expected for staff to have a license before hire, although the AD was not providing direct care to residents. The facility's management roster listed the AD as the Activities Director, and the job description required the AD to be eligible for certification by a recognized accrediting body. The failure to have a qualified AD could potentially impact the quality of life for residents due to a lack of individualized activities.
Failure in Resident Transfer and Discharge Communication
Penalty
Summary
The facility failed to ensure proper documentation and communication during the transfer and discharge of a resident, identified as Resident #5, who was sent to the hospital for a left clavicle fracture. The resident, a female with severe cognitive impairment and multiple health issues, was transferred to the emergency room (ER) after an unwitnessed fall. The facility did not follow up with the hospital to obtain discharge paperwork or new care orders upon the resident's return, which was facilitated by the resident's family due to communication issues with the facility. Interviews with staff revealed a breakdown in communication and protocol adherence. LVN C sent the resident to the hospital but did not ensure that the necessary follow-up was conducted. LVN B, who was on duty when the resident returned, did not receive or seek out discharge paperwork or new orders from the hospital. The facility's liaison, responsible for obtaining clinical updates, was not informed of the resident's return and thus did not follow up with the hospital. The Director of Nursing (DON) acknowledged the communication failures and the lack of post-hospital care orders, which put the resident at risk. The facility's administrator expected staff to use a group chat for communication about residents sent to the ER but did not require follow-up unless the resident was admitted to the hospital. The administrator also noted that it was unacceptable for a resident to return without discharge paperwork and expected the admitting nurse to obtain a report from the hospital. The facility's policy required obtaining a physician's order for emergency transfers, but the process was not adequately followed, leading to the deficiency.
Infection Control Deficiency Due to Improper Hand Hygiene
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) who did not perform proper hand hygiene before providing Activities of Daily Living (ADL) care to a resident. The resident, an 81-year-old female with a primary diagnosis of metabolic encephalopathy, was observed in her room without a box of gloves or hand sanitizer. The CNA entered the room wearing gloves, touched various surfaces, and then repositioned the resident without performing hand hygiene. This action was contrary to the facility's infection control protocols, which require hand hygiene before and after resident contact and after touching surfaces in the resident's environment. Interviews with the CNA and facility staff revealed a lack of understanding and adherence to infection control practices. The CNA admitted to placing gloves in her scrub pocket, believing they remained clean, and did not recognize the risk of cross-contamination. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that gloves should be taken directly from the box to prevent contamination and that staff should not enter rooms with gloves on due to the risk of cross-contamination. The facility's infection control policy emphasizes the importance of hand hygiene and the availability of necessary supplies in patient care areas.
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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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