River Oaks Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 2416 Nw 18th St, Fort Worth, Texas 76106
- CMS Provider Number
- 675018
- Inspections on file
- 40
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at River Oaks Health And Rehabilitation Center during CMS and state inspections, most recent first.
Incorrect Melatonin Dose Administered After EHR Order Entry Error: A resident with dementia, depression, bipolar disorder, schizophrenia, and insomnia received two 5 mg Melatonin tablets instead of the ordered 5 mg dose because the MAR/EHR reflected the wrong tablet strength after a GDR was entered. The Medication Aide said she followed the MAR and used simple math, while nursing leadership confirmed the order entry error and that the resident was at risk for receiving a higher dose than intended.
Improper insulin pen labeling and unsecured carts were observed in the facility. Two insulin pens had open dates written on the exp date line instead of the proper open-date area, and both south hall and north hall medication carts were found unlocked and unattended. A treatment cart was also left unlocked with wound care supplies and scissors inside, and the DON and ADONs stated carts should remain locked when not in use.
Food was not stored and served in accordance with professional standards in the kitchen. Frozen items in the reach-in freezer were found removed from original packaging without labels or dates, and during lunch service an LPN left a food thermometer in pureed broccoli after the item was reheated and returned to the service line. The Dietary Manager and the LPN stated that food should be labeled and dated and that leaving the thermometer in the food could contaminate it.
Missing Care Plan for Indwelling Catheter: A resident admitted with an indwelling urinary catheter had provider orders for Foley care, urine monitoring, hygiene, infection monitoring, and reassessment of continued use, but the care plan did not include comprehensive catheter care. Staff interviews confirmed that catheter care should be care planned and include monitoring urine output, sediment, color, flow, site condition, and signs of infection.
A resident with intact cognition and multiple serious diagnoses had half bedrails placed on both sides of his bed without a documented side rail assessment, informed consent, or evidence that alternatives were tried first. Staff interviews showed the Maintenance Supervisor was told to install the rails without being shown a signed consent, while RN and ADON staff were unaware the rails were in place or that the required documentation was missing. The resident stated he did not request the bedrails and was never spoken to about them.
Personal Refrigerator Not Maintained at Safe Temperature: A resident with Parkinson's disease and dementia kept meals in her room and had a personal refrigerator that was not cool on observation. Staff found the refrigerator at 48.9 degrees with no thermometer or temperature log, while the DON stated residents monitor their own refrigerators and nursing should help with the contents. The facility policy stated the refrigerator compartment should be maintained at 35-41 degrees.
A resident with an indwelling catheter was observed with the catheter bag and tubing on the floor beside the bed. An RN picked up the bag and hung it back on the bed without replacing it, even though she stated the bag was already contaminated. The ADON stated the bag should have been removed and replaced, and the facility’s catheter care policy stated the tubing and drainage bag should be kept off the floor.
Two residents with complex medical conditions did not have their catheter bag emptying and drainage amounts documented on two night shifts, despite facility policy and professional standards requiring this information. The responsible LPN acknowledged the omission, and both the Administrator and DON confirmed the importance of accurate documentation for proper care.
Two unidentified pills were found on a resident's bedside table, despite the resident not being authorized to self-administer medications and having moderate cognitive impairment. The resident was unaware of the pills, and the nurse responsible for medication administration did not notice them. Facility policy requires direct observation of medication ingestion and secure storage, which was not followed in this instance.
A resident with multiple medical conditions alleged inappropriate touching by an LVN during catheter care. The LVN did not immediately report the allegation to the administrator, resulting in a two-day delay before the administrator became aware and the incident was reported to the State Survey agency, contrary to facility policy requiring immediate reporting.
A resident with a history of cerebrovascular disease, hypertension, and diabetes experienced significant weight loss over several months due to ineffective implementation of a person-centered care plan. Despite documented meal refusal and food preferences, staff did not consistently provide preferred foods or initiate additional interventions such as nutritional supplements, and the dietitian only assessed residents after significant weight loss had occurred.
A resident with a history of cerebrovascular disease, hypertension, and diabetes experienced significant weight loss over several months without documented assessment or intervention by the Dietitian. Despite a care plan outlining specific nutritional interventions, these were not fully implemented, and the facility did not follow its own policy for addressing significant weight changes. Interviews confirmed that the resident's poor appetite and food preferences were not adequately addressed, and no supplements were provided.
The facility failed to prepare meals that conserve nutritive value, flavor, texture, and appearance, affecting three residents on regular diets. Observations revealed that the potato casserole was crunchy and the coleslaw was unpalatable. The dietary manager admitted to not tasting the food before serving, and the cook used a deep pan instead of shallow pans, affecting the cooking process. The DON acknowledged the risk of weight loss due to unappetizing meals, and the Administrator expected adherence to recipes and tasting before serving.
A LTC facility failed to maintain infection control measures, with staff neglecting hand hygiene and proper use of PPE. A medication aide did not sanitize hands or equipment after caring for a resident on Enhanced Barrier Precautions. An LVN did not wear a gown during wound care and mishandled soiled towels. An RN failed to sanitize hands after handling a resident's radio, then assisted another resident. These actions violated the facility's infection control policies.
A resident with mental health conditions refused care, leading to unsanitary conditions in her room, including urine and feces, and a strong odor affecting the hallway. Despite staff attempts to clean and provide care, the resident remained resistant, and the facility determined they could not meet her needs.
A resident with a history of mental health disorders consistently refused hygiene care, leading to a deficiency in maintaining her activities of daily living. Despite being independent in other areas, the resident's refusal to bathe was documented over several months, with staff making multiple attempts to provide care. The facility ultimately determined they could not meet her needs, resulting in her transfer to a hospital for evaluation.
A resident with schizophrenia and bipolar disorder was found to have 28 olanzapine tablets in her nightstand, indicating non-compliance with her prescribed medication regimen. Despite being observed accepting medication, she did not ingest the pills, leading to a failure in pharmaceutical services. Staff reported her aggressive behavior and refusal of care, complicating efforts to ensure proper medication administration.
A resident with severe dementia was physically assaulted by another resident with a history of aggression in the dining room. The assaulted resident sustained bruises, and the incident was witnessed by the Dietary Manager. The facility failed to prevent the altercation due to inadequate monitoring and staff presence.
Two residents experienced deficiencies in medication management due to the facility's failure to reorder medications timely. One resident did not receive Tramadol for pain, while another missed hydrocodone doses due to pharmacy and insurance issues. The facility's policy on timely medication reordering was not followed, leading to unmanaged pain.
The facility failed to ensure that food stored in the refrigerator, freezer, and pantry was labeled, dated, and sealed properly. Observations revealed multiple items in the refrigerator, pantry, and freezer that were not labeled, dated, or sealed, despite the facility's policy requiring these actions. Interviews with dietary staff confirmed the importance of these practices to prevent food contamination and food-borne illnesses.
Incorrect Melatonin Dose Administered After EHR Order Entry Error
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when a Medication Aide administered two 5 mg Melatonin tablets to a resident instead of the ordered 5 mg dose. The resident was a female with diagnoses including non-Alzheimer's dementia, depression, bipolar disorder, schizophrenia, and COPD, and her MDS reflected no cognitive impairment with a BIMS score of 15. Her care plan identified insomnia, and the pharmacist had recommended a gradual dose reduction for Melatonin from 10 mg at bedtime to 5 mg at bedtime, which the Medical Director approved. The resident's April 2026 physician's orders reflected Melatonin 5 mg by mouth daily for insomnia, but the MAR showed that the Medication Aide gave two 5 mg tablets on multiple dates instead of one tablet. During interview, the Medication Aide stated she gave two tablets because the MAR reflected 10 mg and she used simple math to equal the 10 mg order. She also stated she was unaware that a gradual dose reduction had been attempted and that she relied on the MAR for administration. Interviews with nursing leadership showed that the incorrect order entry into the EHR contributed to the error. RN B stated she had not reviewed the night shift medication order and would have called the doctor for clarification if she had seen it. ADON C stated the Regional Compliance Nurse entered the pharmacy recommendation into the EHR but did not change the Melatonin 10 mg tablet to a 5 mg tablet, and the Regional Compliance Nurse confirmed she decreased the order but did not change the tablet strength. The Medical Director stated she agreed with the pharmacist to attempt the gradual dose reduction from 10 mg to 5 mg, and the resident stated she slept well and had not noticed daytime grogginess.
Improper Insulin Pen Labeling and Unlocked Medication and Treatment Carts
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles for 2 of 9 insulin pens with correct open dates. During an observation of the south hall nurses’ medication cart, the cart was left unlocked and unattended, and a Novolin R insulin pen for Resident #30 was labeled with a date written on the line for expiration date. RN A stated that the date was intended to be the open date and that she did not know why it was written on the expiration date line. She also stated an opened insulin pen expires 28 days after opening and that the medication cart should always be kept locked, but she had forgotten to lock it. During an observation of the north hall nurses’ medication cart, five insulin pens were inside the cart, and Resident #44’s insulin pen was labeled with a date on the line marked exp date. ADON C stated nurses should not label insulin pens with the open date on the expiration date line because it could cause confusion about the actual open date, and that insulin pens expire after 28 days of opening. In addition, a treatment cart on north hall was observed unlocked and unattended, containing wound care dressings, wound cleanser, cream, and scissors. ADON D stated all carts should stay locked at all times when not in use and that the treatment cart should not have remained unlocked.
Food Storage and Service Line Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During observation on 04/14/2026, two bags of frozen pancakes removed from their original boxes and placed in plastic freezer bags, two bags of chicken nuggets removed from their original boxes, and one bag of hushpuppies were found in the reach-in freezer without labels or dates. The record review included the facility policy on food received and storage, which required food removed from its original container to be labeled with the name of the food item and dated with the month, day, and year. During lunch service observation on 04/15/2026, puree broccoli had an initial service line temperature of 137 degrees and was removed from the service line and placed in the facility oven for additional warming. After being returned to the service line and re-temped at 163 degrees, [NAME] C did not remove the food thermometer. At 11:28 A.M., lunch service had started and the thermometer was still laying in the pureed broccoli; [NAME] C removed it at 11:42 A.M. The Dietary Manager stated that not removing the thermometer could cause it to explode in the food, and [NAME] C stated food should be labeled with date received and used by so expired food is not cooked and in case of a recall, and that leaving the thermometer in the food could break and contaminate the food.
Missing Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #38 related to an indwelling urinary catheter. The resident’s face sheet listed the presence of an indwelling catheter as an admitting diagnosis, and the admission note documented that the resident was admitted with a urinary catheter size 16. The provider’s progress note included orders to continue Foley catheter care, monitor urine output and characteristics, maintain catheter hygiene, monitor for infection, and reassess the need for continued catheter use. Review of the resident’s care plan showed that, despite these catheter-related needs and orders, there was no comprehensive care plan addressing catheter care. During interviews, RN B, RN A, the ADON, and the DON all stated that residents with indwelling catheters should have a care plan and described catheter monitoring and care elements such as urine output, sediment, urine color, flow, site condition, and signs of infection. The facility’s comprehensive care planning policy stated that care plans should describe services to attain or maintain the resident’s highest practicable well-being and be person-centered, and the catheter care policy stated to review the resident’s plan of care daily for changes.
Bedrails Installed Without Assessment or Informed Consent
Penalty
Summary
The facility failed to attempt alternatives before installing half bedrails on both sides of Resident #9's bed, failed to obtain informed consent before installation, and failed to ensure correct installation and maintenance of the bedrails. Record review showed that Resident #9 was a cognitively intact male with a BIMS score of 15 and diagnoses including type 2 diabetes mellitus, cerebrovascular accident, bilateral below-the-knee leg absence, and dependence on renal dialysis. His MDS did not address bedrail use, and his care plan addressed bed mobility assistance but did not reflect bedrails. The EHR also showed no side rail evaluation. Observation on 04/14/26 showed half bedrails on both sides of Resident #9's bed. The Maintenance Supervisor stated that the previous DON told him to place the bedrails on the resident's bed, but he was not shown a signed consent despite asking for it. He stated he understood consent was needed to show the resident had been evaluated and agreed to the bedrails, and he said he should have notified the Administrator before installing them when consent was not provided. He also stated he checks the rails weekly to ensure they are securely placed. Interviews showed staff were unaware of the bedrails or the required documentation. RN B stated she did not know Resident #9 had half bedrails and said she did not believe they were a restraint, though she acknowledged a resident could get an arm stuck and be hurt and that an assessment should be completed before bedrails are placed. ADON C stated Resident #9 should have had an assessment, care plan, and consent, and the DON stated residents with half bedrails should have a bedrail assessment, consent, care plan intervention, and nurse documentation. Resident #9 stated he did not request the bedrails, no staff spoke with him about them, and he was not given a consent or assessment. The facility policy stated alternatives should be attempted before installing bedrails and that assessment, informed consent, and proper installation and maintenance were required.
Personal Refrigerator Not Maintained at Safe Temperature
Penalty
Summary
The facility failed to help family and visitors understand safe food handling practices for Resident #8's personal refrigerator and failed to ensure the in-room refrigerator met safe cooling and reheating temperature standards. Resident #8 was an [AGE]-year-old female admitted on [DATE] with Parkinson's Disease without Dyskinesia and secondary dementia in other diseases classified elsewhere. Her care plan dated 04/06/2026 stated she was on a regular diet, chose to eat all meals in her room, and required monitoring and documentation of meal intake. Her quarterly MDS assessment dated [DATE] showed a BIMS score of 12, indicating moderate cognitive impairment, and Section GG indicated she needed setup or clean-up assistance for eating. On 04/14/2026 at 11:00 AM, observation showed Resident #8 had a personal refrigerator in her room that did not feel cool when opened, and there was no inside thermometer or temperature log. Later that day, the Maintenance Supervisor checked the refrigerator and found the temperature was 48.9 degrees, with the control set to 1. The Maintenance Supervisor stated on 04/16/2026 that the family member or responsible party was responsible for maintaining personal refrigerators. The DON stated on 04/16/2026 that residents monitor their own refrigerators, nursing should help with the content, and direct care staff should throw away spoiled food. The Housekeeper Supervisor stated personal refrigerators were cleaned by housekeeping when alerted by the DON, and housekeeping would remove expired items with the resident present. The facility policy for Personal Refrigerator stated housekeeping can assist the resident and/or family member by inspecting refrigerators at least weekly and that the refrigerator compartment should be maintained at 35-41 degrees.
Catheter Bag Contamination During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for catheter care for one resident with an indwelling catheter. The resident’s face sheet showed admission with a diagnosis of presence of an indwelling catheter, and the provider’s progress note included orders to continue Foley catheter care, monitor urine output and characteristics, maintain catheter hygiene, monitor for infection, and reassess the need for continued catheter use. The resident’s care plan, dated 3/31/2026, did not include care planning for the urinary catheter. During observation, the resident was sleeping while the catheter bag and tubing were found on the floor next to the bed. The DON saw the bag on the floor and informed RN A. RN A performed hand hygiene, donned PPE, entered the room, picked up the catheter bag, and hung it back on the bed without replacing the bag. RN A later stated the bag was already contaminated because it had been on the floor and that she should have removed it and changed it. The ADON stated that if a catheter bag was on the floor, it should be immediately removed and replaced because it was already contaminated, and that staff were expected to follow the facility’s catheter care policy, which stated the catheter tubing and drainage bag should be kept off the floor.
Failure to Document Catheter Care in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents who required documentation of catheter care. Specifically, on two separate night shifts, there was no documentation on the Treatment Administration Records regarding the emptying of catheter bags or the amount of drainage for both residents. The nurse assigned to those shifts confirmed that she was responsible for the documentation and acknowledged that the catheter bags were emptied by an aide, but she did not record the procedure or the amounts as required. Both residents had significant medical histories, including conditions such as Parkinson's Disease, dementia, parastomal hernia, benign prostatic hyperplasia, and major depressive disorder. The lack of documentation was confirmed through interviews with the nurse, the Administrator, and the DON, all of whom recognized the importance of accurate record-keeping. The facility's policy required regular assessment and documentation for residents using urinary devices, but this was not followed on the identified dates.
Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when two unidentified pills were found on a resident's bedside table, despite the resident not being authorized to self-administer medications. The resident, who had a BIMS score indicating moderate cognitive impairment and diagnoses including type 2 diabetes, chronic kidney disease, and heart failure, was unaware of the pills' presence. The pills were discovered during an observation and interview, and the resident stated that he may have dropped them when taking his medication. The Wound Care nurse confirmed that medications should not be left at the bedside and removed the pills from the room. Further interviews revealed that the nurse responsible for administering the resident's medication had not noticed the pills on the left side of the bed and stated that she would have removed them if she had seen them. Facility policy requires that medications be administered directly to residents and observed to ensure ingestion, with any refusals documented and reported. The facility's policies also specify that medications must be stored securely and only accessed by authorized personnel. The presence of unsecured medication at the bedside was contrary to these protocols.
Failure to Timely Report Alleged Abuse to State Agency and Administrator
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported to the State Survey agency and the facility administrator immediately, but not later than two hours after the allegation was made, as required. Specifically, a male resident with a history of cerebral infarction, heart failure, and bipolar disorder, who was cognitively intact and required catheter and incontinent care, alleged that an LVN touched him inappropriately during catheter care. The incident occurred on 03/08/25, but the LVN did not immediately report the allegation to the administrator. Instead, the administrator became aware of the incident two days later, on 03/10/25, after finding a note left by the LVN. An assessment and investigation were initiated only after the administrator learned of the incident, and the report to the State Survey agency was also delayed until 03/10/25. The facility's own policy required immediate reporting and investigation of all abuse allegations, but this protocol was not followed in this case. The delay in reporting was confirmed through interviews, record reviews, and a review of the state database, which showed discrepancies in the reporting timeline.
Failure to Implement Comprehensive Care Plan for Resident with Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and time frames to address the medical, nursing, mental, and psychosocial needs of a resident experiencing weight loss. The resident, who had a history of cerebrovascular disease, hypertension, and type 2 diabetes, was admitted with a stable weight but experienced a gradual decline over several months. Despite the care plan identifying the risk for weight loss due to meal refusal and food preferences, interventions such as providing preferred foods, encouraging meal completion, and monitoring weight were not effectively implemented. The resident's weight decreased from 184.2 lbs to 166.4 lbs over approximately eight months, representing a 9.37% loss. Documentation showed the resident often ate less than 51% of meals, preferred snacks brought by family, and expressed dissatisfaction with facility food. The care plan included goals to maintain ideal weight and interventions like determining food preferences and serving snacks, but these were not consistently followed. The facility's policy required intervention only after a 10% weight loss in six months, and staff did not initiate additional measures such as nutritional supplements or further dietary assessment before reaching this threshold. Interviews with staff revealed that the dietitian only assessed residents with significant weight loss and did not document recommendations for further evaluation. Nursing staff noted the resident's poor meal intake but did not implement new interventions. The resident's family was aware of the ongoing weight loss and dissatisfaction with meals, but no documented changes were made to address these concerns prior to the deficiency being identified.
Failure to Address Resident Weight Loss and Implement Nutritional Interventions
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, specifically regarding weight loss, as required by regulation. One resident experienced a 9.37% weight loss over eight months, with no documentation from the Dietitian addressing nutritional concerns or recommending interventions to address the weight loss. The resident's care plan included interventions such as determining food preferences, encouraging meal completion, monitoring weight, and regular Dietitian assessments, but these interventions were not fully implemented. The resident had a history of cerebrovascular disease, hypertension, and type 2 diabetes, and was on a regular diet with no supplements. Despite a documented poor appetite and a preference for certain foods, there was no evidence that the Dietitian assessed the resident or made recommendations during the period of weight loss. The resident's weight was recorded monthly, showing a steady decline, but the facility did not initiate additional interventions or document follow-up actions as outlined in their own policy for significant weight changes. Interviews revealed that the Dietitian only assessed residents with significant weight loss and did not document a conversation regarding a possible swallowing evaluation. The nursing staff noted the resident was eating less than 51% of meals, but no supplements were provided, and the resident's family expressed concern about the ongoing weight loss. The facility's policy required action for significant weight changes, but these steps were not taken or documented for this resident.
Deficiency in Food Preparation and Quality
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, flavor, texture, and appearance for residents on regular diets. This deficiency was observed in three residents who were served meals that were not palatable or properly cooked. Specifically, the potato casserole served was crunchy and not fully cooked, and the coleslaw was unpalatable and not set in form. These issues were confirmed through observations and interviews with the residents, who expressed dissatisfaction with the meals, and the dietary manager, who admitted to not tasting the food before serving it. The dietary manager and cook revealed that the potato casserole was prepared in a deep pan instead of two shallow pans, which affected the cooking process, and the coleslaw dressing was improvised due to a lack of ingredients. The dietary manager also admitted to not tasting the food before it was served, which is against the facility's policy. The Director of Nursing acknowledged the risk of weight loss and other health issues due to unappetizing meals, and the Administrator expected the dietary staff to follow recipes and taste the food before serving. The facility's policy requires a test tray evaluation to ensure food quality, which was not adhered to in this instance.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by multiple incidents involving staff and residents. One incident involved a medication aide (MA A) who did not perform hand hygiene after measuring the blood pressure of a resident on Enhanced Barrier Precautions (EBP). Instead of sanitizing his hands immediately, MA A attempted to enter another resident's room to wash his hands, which was stopped by the surveyor. Additionally, MA A did not properly sanitize the blood pressure machine and its components after use, potentially risking cross-contamination. Another incident involved a Licensed Vocational Nurse (LVN D) who did not adhere to EBP procedures during wound care for a resident. LVN D failed to wear a gown upon returning to complete the wound care and improperly handled soiled towels by placing them under his arm instead of in a designated bag. This oversight occurred despite LVN D's awareness of the EBP requirements, as he was one of the infection control preventionists at the facility. A third incident involved a Registered Nurse (RN E) who neglected to sanitize her hands after handling a resident's radio, which had been inside the resident's pants. RN E then proceeded to assist another resident without performing hand hygiene, increasing the risk of infection transmission. These actions were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene and proper use of personal protective equipment to prevent the spread of infections.
Failure to Maintain a Safe and Sanitary Environment for a Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident diagnosed with paranoid schizophrenia, bipolar disorder, and dementia, among other conditions. The resident, who had a history of hoarding and refusing care, did not allow staff to clean her room or provide personal hygiene assistance. This resulted in unsanitary conditions, including urine and feces in the room, and a strong odor that permeated the hallway. Despite multiple attempts by housekeeping and nursing staff to clean the room and provide care, the resident remained resistant and aggressive, refusing access to her room. The facility's staff, including the Director of Nursing and Administrator, were aware of the situation and noted a deterioration in the resident's condition since August, with behaviors such as voiding in plastic bags and hoarding items from the facility. Meetings with the interdisciplinary team and external healthcare providers were held, but the facility determined they could not meet the resident's needs. Observations confirmed the unsanitary state of the resident's room, with personal items and facility property scattered throughout, and writing on the walls. Interviews with staff revealed ongoing challenges in managing the resident's behaviors and maintaining a sanitary environment. The facility's admission packet outlined the residents' right to live in safe, clean conditions, which was not upheld in this case.
Failure to Maintain Resident's Hygiene and ADL
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable due to clinical conditions. Specifically, the facility did not ensure that a resident was provided with adequate hygiene care. The resident, who had a history of paranoid schizophrenia, bipolar disorder, and dementia, consistently refused showers and other hygiene-related care. Despite being independent in other functional activities, the resident's refusal to bathe was documented repeatedly over several months, with staff making multiple attempts to provide care each day. The resident's care plan indicated that she required supervision for bathing, yet the facility's records showed a pattern of refusal and lack of intervention to address the underlying issues contributing to the resident's non-compliance. The resident's refusal to bathe led to concerns about her hygiene, skin condition, and overall quality of life. Staff interviews revealed that the resident was aggressive and resistant to care, and the facility struggled to manage her behaviors effectively. The situation escalated to the point where the resident was transferred to a hospital for evaluation, as the facility determined they could not meet her needs. The resident's guardian and psychiatric care providers were involved in discussions about her care, but the facility ultimately decided that they could not provide the necessary support for her psychiatric and mental health needs. The report highlights the facility's inability to manage the resident's care effectively, leading to a deficiency in maintaining her activities of daily living.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in ensuring the administration of olanzapine as prescribed. The resident, diagnosed with paranoid schizophrenia, bipolar disorder, and other cognitive impairments, was found to have 28 olanzapine tablets in her bedside nightstand drawers. These tablets were supposed to be taken twice daily, but the resident was not compliant with the medication regimen, as evidenced by the accumulation of pills in her room. The resident's medical records indicated a history of non-compliance with medication, including refusal of Risperdal injections and hoarding behavior related to her psychiatric conditions. Despite being observed accepting medication cups, the resident was not ingesting the pills, instead storing them in her drawers. This behavior was reported by a CMA, who noticed the pills in the drawer and informed the charge nurse, leading to further investigation by the DON and Administrator. Interviews with staff revealed that the resident was aggressive and refused care, including medication administration. The DON, upon searching the resident's room, found the olanzapine tablets, which appeared to have been in contact with liquid and were sticking together. The resident denied having the medication and reacted angrily to the search, indicating a lack of cooperation with the facility's efforts to ensure proper medication administration. The facility's policy on medication administration and refusal was not effectively implemented, resulting in the resident not receiving her prescribed medication.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with severe dementia and cognitive impairment, who was physically assaulted by another resident with intact cognition but a history of behavioral issues, including verbal and physical aggression. The assaulted resident had a history of behavioral problems and was at risk for injury due to wandering and impaired cognitive function. The incident occurred in the dining room area, where the resident with dementia was approached by the other resident, who then physically assaulted him by punching him in the face and holding onto his wrist. This altercation was witnessed by the Dietary Manager, who intervened and separated the two residents. The assaulted resident sustained bruises on his right forearm and left eye, which were assessed by an LVN as new injuries. The facility's failure to prevent this incident was further highlighted by the lack of staff presence in the dining room at the time of the altercation, as noted by the resident who committed the assault. Despite previous reports of behavioral issues, the facility did not adequately monitor or separate the residents to prevent such an incident. The facility's policy on abuse and neglect, which includes resident-to-resident abuse, was not effectively implemented to protect the residents involved.
Deficiencies in Medication Management for Pain Relief
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. Resident #3, a male with diagnoses including alcoholic cirrhosis, major depressive disorder, and type 2 diabetes, did not receive his prescribed Tramadol for pain management. Despite having an order for Tramadol to be administered every 8 hours as needed, the medication was not reordered in a timely manner, resulting in the resident experiencing unmanaged pain. Interviews with nursing staff revealed that the medication was not reordered when supplies were low, and the emergency kit did not contain the necessary medication. Resident #4, a male with type 2 diabetes, morbid obesity, and chronic pain, also experienced issues with medication management. The resident's hydrocodone doses were missed due to delays in pharmacy delivery and insurance issues, leading to a period of eight days without the medication. The resident reported that his pain was managed except during this period. The facility's policy required medications to be reordered three to four days in advance, but this was not adhered to, resulting in missed doses and potential pain management issues. The facility's policy on ordering medications was not followed, as medications were not reordered in a timely manner, leading to residents going without necessary pain management. Interviews with staff, including the DON and Administrator, highlighted expectations for timely reordering, but these were not met, resulting in deficiencies in pharmaceutical services. The lack of adherence to the policy and failure to manage medication supplies effectively contributed to the residents' unmet needs for pain management.
Failure to Properly Label, Date, and Seal Food Items
Penalty
Summary
The facility failed to ensure that food stored in the refrigerator, freezer, and pantry was labeled, dated, and sealed properly. During an observation, several items were found in the refrigerator, including cooked bacon and sausage patties, sausage patties in opened plastic packaging, cooked green beans, tuna salad, red sauce, ground meat, sliced meat, and marinara sauce, all of which were not labeled, dated, or sealed properly. Similar issues were found in the pantry and freezer, where items such as cereal, French onion topping, instant milk, frozen breadsticks, and frozen meat were not labeled, dated, or sealed. These deficiencies were confirmed through interviews with the dietary manager, dietary aide, and cook, who acknowledged the importance of proper labeling, dating, and sealing to prevent food contamination and food-borne illnesses. The facility's policy on food receiving and storage, which was last revised in October 2017, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated. Despite this policy, the staff failed to adhere to these guidelines, as evidenced by the observations and interviews. The dietary manager admitted that all dietary staff were responsible for ensuring proper labeling, dating, and sealing of food items, and that she was responsible for training the staff. However, the observed deficiencies indicate a lapse in adherence to these professional standards, potentially placing residents at risk for food contamination and food-borne illnesses.
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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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