The Bartlett Skilled Nursing And Assisted Living
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 221 Bartlett Drive, El Paso, Texas 79912
- CMS Provider Number
- 676457
- Inspections on file
- 31
- Latest survey
- April 11, 2026
- Citations (last 12 mo.)
- 26
Citation history
Health deficiencies cited at The Bartlett Skilled Nursing And Assisted Living during CMS and state inspections, most recent first.
A resident with dementia, mild intellectual disability, ESRD on dialysis, depression, and behavioral issues was hospitalized for SOB and low O2 saturation. The facility’s bed-hold policy required written notice of bed-hold and return rights and mandated that residents be permitted to return after hospitalization unless formal discharge procedures were followed. The Executive Director acknowledged that no bed-hold was offered, no written notice was provided, and no 30‑day discharge notice or discharge documentation was completed. When the hospital sought to return the resident, the Executive Director stated there were no available beds and that the resident could not share a semi-private room due to a prior incident of hitting a roommate, despite census records showing an available female bed. The PASRR supervisor and the resident’s guardian reported multiple unanswered attempts to coordinate the resident’s return and stated the Executive Director made it clear he did not want the resident back. The resident’s belongings were packed by staff and handed to the guardian at the entrance, with missing items not documented through a grievance process. These actions and omissions resulted in the resident not being readmitted from the hospital in accordance with the facility’s own bed-hold and return policy.
Surveyors found that the facility did not follow its own background check and abuse prohibition policies for an LVN MDS nurse and a housekeeper. Records and interviews showed that required criminal history checks were not initiated and completed within the timeframes specified in facility policy, including completion prior to employment for direct access staff. These lapses occurred despite written policies requiring timely background screening and prohibiting employment of individuals with certain abuse-, neglect-, or exploitation-related findings.
Two residents’ medical records were not accurately or completely documented. For one resident with dementia, intellectual disability, ESRD, and behavioral issues, the facility failed to record a room change, a multidisciplinary family meeting about discharge, communications with the hospital when the resident was not re-admitted after hospitalization, the absence of a bed-hold or 30-day notice, and the guardian’s retrieval of belongings and report of missing items. For another resident with ESRD, diabetes, hypertension, cognitive impairment, and poor vision, staff did not document a report from a dialysis center that the resident’s cell phone was missing, nor the subsequent awareness by the DON and an LVN of the lost phone, despite a policy requiring documentation of events and incidents in the medical record.
A resident with ESRD on dialysis, diabetes, and moderate cognitive impairment reported through a dialysis center that his cell phone was missing, but facility staff did not follow the written grievance policy. The receptionist documented the concern only on a sticky note and did not complete a grievance form, stating she was unaware of the grievance process. The DON recalled a call about the missing phone but did not document a grievance, and the CNA Manager, though notified, did not complete grievance paperwork and was unaware of the policy. Other staff gave inconsistent accounts about the missing phone, and the Administrator and Executive Director were unaware of the issue. Review of the grievance policy showed the grievance officer was not identified and required written investigation and reporting for complaints such as theft of property, which was not done in this case.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have effective policies and procedures in place to prevent abuse, neglect, and theft, as evidenced by gaps in staff training and unclear guidance on reporting and prevention. This created an environment where such incidents could occur without prompt detection or intervention.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A facility failed to document a physician's verbal order to hold Donepezil for a resident with Lewy body dementia due to potential interactions with antibiotics. The medication was not listed in the resident's MAR, and the physician's progress notes incorrectly continued to include it. The DON confirmed the lack of documentation and stated that the resident remained stable during their stay.
A facility failed to change a resident's PICC line dressing as ordered, despite the dressing being intact and showing no signs of infection. The resident, with a history of falls, metabolic encephalopathy, and pneumonia, had a PICC line in her left upper arm. The physician's order required weekly dressing changes, but observations revealed the dressing was not changed by the seventh day. Interviews with staff confirmed the oversight, highlighting a deficiency in intravenous care management.
A medication cart was left unattended and unlocked in a facility hallway, posing a risk of unauthorized access to medications. A CNA noticed and locked the cart, while LVN A admitted to leaving it unsecured while attending to a resident. The facility's policy requires carts to be locked when not in use, and staff are trained on this protocol.
The facility failed to provide mandatory training on its QAPI program to all staff, including key personnel like the Administrator and DON. This deficiency was identified through interviews and record reviews, revealing that 16 employees did not receive training on the QAPI program's elements and goals, despite it being a required topic in the facility's policy. The lack of training was confirmed by the HR Manager and acknowledged by the Administrator-in-training, highlighting a risk to residents due to staff unawareness of quality control concerns.
The facility failed to document post-dialysis assessments for two residents, risking complications. One resident with severe cognitive impairment and end-stage renal disease had bleeding at the dialysis site, which was not documented. Another resident with chronic kidney disease lacked a care plan and post-dialysis documentation. The facility's policy did not address documentation, and the DON acknowledged the deficiency.
The facility failed to ensure appropriate use of psychotropic medications for residents, with two residents receiving Risperidone without proper diagnoses and another resident having a PRN order for Lorazepam without a 14-day limit. The DON acknowledged the oversight, highlighting the importance of regulatory compliance to prevent overuse and ensure medication effectiveness.
The facility failed to maintain food safety standards, with unlabeled and improperly stored food items found in the kitchen. Unsealed cilantro, overripe fruit, and improperly thawed meat posed contamination risks. The Dietary Director acknowledged these lapses, which violated the facility's food storage policy.
A long-term care facility failed to maintain an effective infection control program, as evidenced by a resident's catheter bag being left on the floor and staff not adhering to proper hand hygiene and glove-changing protocols during incontinent care. Interviews revealed a misunderstanding of infection control policies, contributing to these deficiencies.
A facility failed to create a comprehensive care plan for a resident with diabetes and renal dialysis needs. Despite the resident's medical history and treatment requirements, the care plan did not address these conditions. Staff interviews acknowledged the oversight, but relied on MAR documentation for monitoring. The facility's policies lacked guidance on comprehensive care plans.
A resident with dementia was prescribed Risperidone without appropriate diagnosis or GDR attempts. Despite repeated recommendations from the Pharmacist Consultant to reduce or discontinue the medication, the physician did not respond, and the medication continued. The facility's policy required documentation of why the benefits outweighed the risks, which was not provided.
A facility failed to maintain accurate clinical records for a resident on hemodialysis by not labeling communication forms with resident-identifying information. This oversight prevented proper documentation in the resident's electronic chart. The resident, with multiple health issues, required specific monitoring post-dialysis, which was not adequately documented. Interviews with the ADON and DON revealed a lack of awareness and adherence to documentation policies.
Failure to Follow Bed-Hold and Return Policy After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to follow its own written bed-hold and return policy and to permit a long-term resident to return after a hospitalization. The resident had been originally admitted in 2019, with a re-admission in 2023, and had multiple diagnoses including unspecified dementia, mild intellectual disability, major depressive disorder, anxiety, and end-stage renal disease requiring dialysis. Her MDS documented severe cognitive impairment (BIMS score 4), impaired vision, and a need for assistance with ADLs, as well as behavioral issues such as yelling, hitting herself, and prior aggression toward others. Care plan and psychiatric documentation showed ongoing use of psychotropic medications (Risperidone) for dementia and aggressive behavior, and staff and psychiatric notes described temper tantrums, verbal aggression, and a history of harming others and combativeness when she did not get her way. On a date in early February, nursing notes and transfer documentation show the resident was sent to the hospital for shortness of breath and decreased oxygen saturation. EMS records indicate she was found on oxygen at the facility with reported O2 saturation dropping to 84%, was placed on a non-rebreather mask, and transported with improved oxygenation. The facility’s own “Bed-Holds and Returns” policy, revised October 2022, states that residents and/or representatives are to be informed in writing of bed-hold policies well in advance of transfer and again at the time of transfer (or within 24 hours for emergencies), and that residents must be permitted to return following hospitalization unless specific discharge criteria are met and facility-initiated discharge requirements are followed. The Executive Director acknowledged that no bed-hold was offered to the resident’s guardian at the time of this hospitalization and that there was no documentation in the clinical record of a bed-hold notice or of the guardian being notified in writing. When the hospital was ready to discharge the resident back to the facility, the Executive Director reported that the resident was not re-admitted because he believed the facility was full and that only a semi-private bed was available, which he deemed inappropriate due to a prior incident in July 2025 when the resident had hit a roommate. He stated he had decided the resident could not have a roommate and that the facility had been cited previously related to that incident. Census reports for mid-February, however, showed an empty female bed in a specified room on multiple consecutive days. The PASRR Unit Supervisor and the resident’s guardian reported that the Executive Director made it clear he did not want the resident to return, did not respond to multiple calls and an email from PASRR and the guardian regarding the resident’s hospital discharge, and told them there were no beds available. The Executive Director also confirmed that no 30‑day discharge notice was issued, that there was no documentation of the October family meeting in the resident’s record, and that the facility did not document the guardian’s report of missing personal items or complete a grievance form. The guardian stated that when she came to pick up the resident’s belongings, she was kept at the entrance, handed pre-packed boxes, noted missing items, and was told staff did not know what happened to them. The facility’s actions and omissions resulted in the resident not being allowed to return after hospitalization, contrary to the facility’s written bed-hold and return policy and without following required facility-initiated discharge procedures. Interviews with multiple staff members, including LVNs and a CNA, confirmed the resident’s long-term status at the facility, her behavioral patterns (temper tantrums, cursing, hitting herself, throwing items), her dialysis schedule, and that she had been moved from a private to a semi-private room prior to the July 2025 roommate incident. Staff recalled being told, informally, that the resident could not have a roommate but did not know the formal basis. The PASRR Unit Supervisor and guardian described an earlier family conference in October 2025 with the Executive Director, DON, MDS nurse, ombudsman, and others, during which the Executive Director stated the facility had converted to a short-term stay model and that the resident should be placed in a more stable LTC setting. Despite this, there was no documentation of a formal discharge plan or 30‑day notice in the record, and when the resident was hospitalized for pneumonia and ready for discharge, the facility did not readmit her, did not provide required written notices, and did not document the decision as a facility-initiated discharge in accordance with policy and regulatory requirements. The facility’s own policy states that residents, regardless of payer source, must be permitted to return following hospitalization or therapeutic leave, and that if the facility determines a resident cannot return, it must comply with facility-initiated discharge requirements, including appropriate notice and documentation. The Executive Director acknowledged that the facility did not offer a bed-hold at the time of transfer, did not issue a 30‑day discharge notice, did not document the October family meeting, and did not document the guardian’s grievance about missing belongings. The PASRR Unit Supervisor and guardian reported that the resident remained in the hospital until another facility could be found, and the guardian stated that the resident had been at the original facility for seven years and considered it her home. These documented actions and inactions by the facility and its leadership led directly to the deficiency related to failure to follow bed-hold and return policies and failure to properly manage a facility-initiated discharge when the resident was hospitalized and ready for return.
Failure to Follow Background Check Policy for Direct Access Staff
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation through timely criminal history checks. Interview and record review with the Human Resources staff showed that an LVN MDS nurse and a housekeeper did not have criminal history checks completed in accordance with facility policy. For the LVN MDS nurse, the date of hire was documented as 10/06/21, while the criminal history check was completed on 09/21/21, indicating the check was not initiated within two days of an offer of employment as required by policy. For the housekeeper, the date of hire was 03/09/26, and the criminal history check was completed on 03/10/26, showing that the check was not completed prior to employment as required. Review of the facility’s 2019 background check policy revealed that background checks, including criminal conviction checks, were to be initiated within two days of an offer of employment or contract agreement and completed prior to employment for all direct access employees. The policy defined direct access employees as individuals with access to residents and one-to-one contact through employment or contract. Additionally, the facility’s Abuse Prohibition Policy, revised April 2021, required the facility to conduct employee background checks and not knowingly employ or engage individuals with findings or disciplinary actions related to abuse, neglect, exploitation, mistreatment, or misappropriation of resident property. The survey findings showed that these policies were not fully implemented for the LVN MDS nurse and the housekeeper.
Failure to Accurately Document Key Events in Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete medical records in accordance with its own documentation policy and accepted professional standards for two residents. For the first resident, who had long-term placement, dementia, mild intellectual disability, ESRD on dialysis, and significant behavioral issues, the facility did not document multiple key events in the electronic clinical record. There was no documentation of the resident’s move from a private room to a semi-private room in July 2025, despite the Executive Director stating this move and a prior altercation with a roommate influenced later decisions about room placement and readmission. The record also lacked any written notification to the resident’s responsible party or the LTC Ombudsman regarding the resident’s discharge when she was sent to the hospital on 2/02/26 for shortness of breath and low oxygen saturation. The facility further failed to document in the first resident’s record that a family meeting was held on 10/09/25 with the Executive Director, MDS nurse, care coordinator, DON, local ombudsman, PASRR supervisor, nurse practitioner, and the resident’s guardian to discuss the need to discharge the resident to another LTC facility. Participants, including the Executive Director and MDS nurse, confirmed the meeting occurred and that it was convened to explain why the resident should be discharged and why the facility believed it could not meet her needs, but they acknowledged that no notes of this meeting were entered into the clinical record. Additionally, when the resident was hospitalized with pneumonia beginning 2/02/26 and was later ready for discharge, the Executive Director informed hospital staff on 2/14/26 that the resident would not be re-admitted due to lack of an appropriate bed and his decision that she could not have a roommate; this communication and decision were not documented in the resident’s record. The Executive Director also acknowledged there was no documentation of offering a bed-hold, no 30-day discharge notice, and no record entry when the guardian came on 2/17/26 to pick up the resident’s belongings, nor any signed personal inventory form or grievance documentation when the guardian reported missing clothing and tennis shoes. For the second resident, who had ESRD on dialysis, diabetes, hypertension, moderate cognitive impairment, and poor vision, the facility failed to document a reported loss of the resident’s cell phone. The receptionist received a call from the dialysis center reporting that the resident stated his cell phone was missing; she wrote the concern on a sticky note and gave it to a nurse, but did not complete a grievance or concern form and was unaware of the grievance policy. The DON later recalled receiving a call from the dialysis center about the missing phone but did not document this in the resident’s clinical record. An LVN also remembered that the resident’s old basic cell phone, which he used to communicate with family via a video-calling app, was lost over a weekend and never found, and she acknowledged she did not document this event. Review of IDT notes and the resident’s record showed no entries about the missing phone, despite the facility’s written policy requiring documentation of events, incidents, or accidents involving the resident in the medical record.
Failure to Follow Grievance Policy for Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint policy and ensure efforts were made to resolve a resident’s grievance regarding a missing cell phone. The resident was an adult male with end stage renal disease on dialysis, Type 2 diabetes, and hypertension, admitted for rehabilitation and occupational therapy, with a BIMS score of 10 indicating moderate cognitive impairment. His admission inventory form documented that he did not want an inventory and his items were not labeled. Interdisciplinary team notes from early September through early October did not document that he had lost his cell phone. A concern about the missing cell phone was first communicated from the resident’s dialysis center to the facility. The receptionist reported receiving a call from someone at the dialysis center stating that the resident reported his cell phone was missing. She wrote the information on a sticky note, gave it to an unidentified nurse, and asked that it be given to the CNA Manager, but she did not complete a grievance/concern form and stated she was unaware of the grievance policy or the need to document such complaints. The DON recalled receiving a call from the dialysis center about the missing phone but did not remember whom she spoke with about it and acknowledged that she did not complete a grievance/concern form. The CNA Manager stated she was notified by the receptionist about the missing phone and alerted laundry staff to look for it, but she did not receive or complete a grievance/concern form and reported she was not aware of the grievance policy. Other staff interviews showed inconsistent awareness and lack of documentation regarding the missing phone. The Administrator stated he was not aware of missing cell phones and could not recall if the Executive Director had reported this concern to him. The DON and LVN ADON did not remember anything about the resident missing a cell phone. One LVN remembered the resident had a cell phone and frequently called his daughter but could not recall if it was lost, while another LVN recalled that the resident lost his old cell phone over a weekend and it was never found, and that staff assisted him with dialing so he could communicate with his family. The Executive Director stated the Social Worker was designated as the Grievance Officer but said he did not know the resident had lost his cell phone. Review of the facility’s grievance policy showed that the grievance officer was not identified by name or contact information, and required that grievances, including those related to theft of property, be investigated and documented, with written findings provided to the resident or representative. No grievance form or written investigation related to the missing cell phone was found in the record.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies Preventing Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. Surveyors identified that the facility did not have comprehensive or consistently enforced protocols in place to safeguard residents from these forms of mistreatment. This deficiency was observed through a review of facility documentation and staff interviews, which revealed gaps in staff training and a lack of clear guidance on reporting and preventing such incidents. The absence of robust preventive measures contributed to an environment where abuse, neglect, or theft could occur without timely detection or intervention.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Document Medication Hold Order for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the medication Donepezil. The resident, diagnosed with Lewy body dementia, was admitted to the facility following surgery. Despite the physician's verbal order to hold Donepezil due to potential interactions with antibiotics, this instruction was not documented in the resident's medical records. The physician's progress notes erroneously continued to list Donepezil as part of the treatment plan, and the medication was absent from the Medication Administration Records (MAR) for the months reviewed. Interviews revealed that the family member was unaware of the medication not being administered and facility staff were not informed of the resident's prescription for Donepezil. The Director of Nursing (DON) acknowledged the lack of documentation regarding the verbal hold order and confirmed that the hospital's medication reconciliation did not specify a dosage for Donepezil. Despite the documentation errors, the resident was reported to have been in stable condition during their stay and upon discharge.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice for the care of a PICC line for a resident, leading to a deficiency in intravenous care. The resident, a female with a history of repeated falls, metabolic encephalopathy, and pneumonia, had a PICC line in her left upper arm. The physician's order required the PICC line dressing to be changed once a week using sterile technique, as well as when the dressing was soiled, wet, or loose. However, observations revealed that the dressing, dated 01/27/25, was not changed by the seventh day as required, despite being intact and showing no signs of infection. Interviews with staff, including an LVN and the DON, confirmed that the dressing should have been changed by the seventh day, and that the responsibility for managing PICC lines lay with the nursing staff. The DON stated that nurses were expected to check the dressing every shift and during every antibiotic administration. The facility's policy also required dressing changes at least every seven days. Despite the lack of immediate signs of infection, the failure to change the dressing as ordered placed the resident at risk of complications associated with PICC lines.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with one of the two medication carts reviewed. On February 3rd, a medication cart located in the 400 hall was left unattended and unlocked, with two staff members present in the hallway. Shortly after, a CNA noticed the unlocked cart and proceeded to lock it. The CNA acknowledged the importance of keeping the cart secured to prevent unauthorized access to medications, emphasizing that it was the nurses' responsibility to ensure the cart remained locked. LVN A, who was responsible for the medication cart, admitted to leaving it unlocked while attending to a resident who was leaving for dialysis. LVN A confirmed having received training on the importance of locking the medication cart and recognized the risk of residents accessing the medications. The Director of Nursing and the Administrator both reiterated that medication carts should be locked at all times when unattended, and that nurses are trained on this requirement upon hire and during annual training. The facility's policy, dated April 2007, mandates that the cart must be locked before the nurse enters a resident's room.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for all staff members, which is a requirement as per their policy. This deficiency was identified during interviews and record reviews, where it was found that 16 employees, including the Administrator, Director of Nurses, Infection Control Preventionist, and other key staff, did not receive training on the elements and goals of the facility's QAPI program. The HR Manager confirmed that no such training was provided to these employees, despite their varying dates of hire. The lack of training was further corroborated by the facility's orientation and training documents, which showed no evidence of QAPI program training for the reviewed employees. The Administrator-in-training acknowledged the absence of formal training on the QAPI program and recognized the potential benefits of such training in making staff aware of the facility's quality-related efforts. The facility's policy on in-service training, revised in August 2022, lists the QAPI program as a required training topic, yet this was not implemented, putting residents at risk of receiving poor-quality services due to staff unawareness of quality control concerns.
Failure to Document Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that dialysis services were provided consistently with professional standards of practice for two residents who required such services. Specifically, the facility did not document post-dialysis assessments in the charts of two residents, which could place them at risk for complications. Resident #7, a female with severe cognitive impairment and end-stage renal disease, was observed with bandages on her dialysis access site, indicating bleeding that was not documented in her chart. Despite having a care plan that included monitoring for complications, there was no post-dialysis documentation in her progress notes for several months. Resident #40, a male with severe cognitive impairment and chronic kidney disease, also did not have a care plan in place for dialysis, and there was no post-dialysis documentation in his progress notes since his readmission. The facility's communication binder for his hall contained only blank forms, indicating a lack of documentation for his dialysis care. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) acknowledged the lack of documentation and were unsure of the facility's policy regarding post-dialysis documentation. The facility's policy on hemodialysis catheter care did not address documentation of pre- and post-dialysis assessments, contributing to the deficiency. The DON admitted that the current documentation was lacking and that the nurses should have been documenting in progress notes when residents returned from dialysis. The absence of proper documentation and care planning for these residents highlights a significant oversight in the facility's dialysis care practices.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents who had not previously used psychotropic drugs were not administered these medications unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was observed in two residents who were given Risperidone without appropriate diagnoses. Additionally, the facility did not limit PRN orders for psychotropic drugs to 14 days for another resident, which is a regulatory requirement. Resident #98, who was receiving hospice care, had a PRN order for Lorazepam without a 14-day limit. Despite the medication not being administered, the lack of a time limit on the PRN order was a violation of regulations. The Director of Nursing (DON) acknowledged the oversight and explained that the 14-day limit is intended to prevent overuse and ensure the medication's effectiveness and tolerance. Resident #7 and Resident #3 were both prescribed Risperidone without appropriate diagnoses. Resident #7's care plan included the use of Risperidone for impulsive disorder, but her psychiatric evaluation did not support this diagnosis. Similarly, Resident #3 was prescribed Risperidone for behavioral disturbances associated with dementia, but pharmacy reviews repeatedly indicated that the medication was not justified. Despite recommendations for gradual dose reduction (GDR) and discontinuation, the medication continued to be administered without proper justification.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that food items were not properly labeled, covered, or sealed. Specifically, an unsealed plastic bag of cilantro and a clear plastic container with unlabeled, overripe fruit were found in the refrigerator. The staff member acknowledged the risk of using such perishable items without knowing their freshness, which could potentially lead to foodborne illnesses among residents. Additionally, a bottle of ranch dressing with dried dressing on the outside and a container of tomato sauce with an unsecured cover were found, posing risks of contamination and pest attraction. Furthermore, the facility did not follow proper procedures for thawing meat. Two briskets were found thawing directly on the refrigerator floor, with juices pooling around them, which could lead to contamination of other foods. The Dietary Director confirmed that the meat should have been placed on a tray to prevent drippings from contaminating the refrigerator. The facility's policy requires all foods to be covered, labeled, and dated, and raw animal products to be stored in drip-proof containers, which was not adhered to in these instances.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during a survey. One significant issue involved a resident's catheter drainage collection bag being left on the floor, which poses a risk of contamination and infection. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), confirmed that the bag should not touch the floor due to the potential for germs to infect the resident. Despite staff being trained to prevent such occurrences, the catheter bag was observed on the floor, indicating a lapse in adherence to infection control protocols. Additionally, the facility's staff did not adhere to proper hand hygiene and glove-changing protocols during incontinent care for two residents. CNAs were observed failing to change gloves after they became contaminated and did not practice adequate hand hygiene. This included not washing hands for the required duration and not using a clean paper towel to turn off the faucet. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that these practices could lead to cross-contamination and were against the facility's infection control policies. The facility's policy on hand hygiene emphasizes the importance of washing hands with soap and water when visibly soiled and using hand sanitizer between glove changes. However, staff interviews revealed a misunderstanding of these protocols, with some staff members believing that double-gloving was an acceptable substitute for proper hand hygiene. This misunderstanding contributed to the observed deficiencies in infection control practices, potentially placing residents at risk for infections.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, specifically neglecting to address the resident's diagnosis of diabetes and dependence on renal dialysis. The resident, who was initially admitted and later readmitted to the facility, had a documented history of diabetes mellitus and was receiving insulin injections. Despite these medical needs being identified in the comprehensive assessment, the care plan did not include diabetes as a focus of care, nor did it specify goals or interventions to manage the condition. Additionally, the care plan lacked any mention of renal dialysis, which was a necessary treatment for the resident's kidney injury. Interviews with facility staff, including the MDS nurse and the DON, revealed an acknowledgment that diabetes should have been included in the resident's care plan. However, they believed that the resident's condition was being monitored through the Medication Administration Record (MAR), which documented blood sugar monitoring. Despite this, the absence of a formal care plan for diabetes and dialysis was noted as a deficiency. Furthermore, when requested, the facility's policies did not provide guidance on developing comprehensive care plans, indicating a gap in policy adherence or availability.
Failure to Act on Pharmacist Recommendations for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for a resident reviewed for physician response to medication regimen review. The resident, who had a history of dementia with behavioral disturbances, was prescribed Risperidone, an antipsychotic medication, without an appropriate diagnosis or attempt at gradual dose reduction (GDR). Despite recommendations from the Pharmacist Consultant to reduce or discontinue the medication, the physician did not respond appropriately, and the medication continued to be administered. The resident's medical records indicated that she had severe cognitive impairment and no recent symptoms of delirium or psychosis. Despite this, she was receiving antipsychotic medication routinely, and no GDRs had been attempted. The pharmacy review notes repeatedly highlighted the lack of justification for the continued use of Risperidone and recommended dose reductions or discontinuation, but these recommendations were not acted upon by the physician. The facility's policy required physicians to document why the benefits of such medications outweighed the risks, but this was not done in this case. Interviews with the Director of Nursing (DON) revealed that the resident should not have been prescribed Risperidone for behavioral disturbance, as it was an inappropriate diagnosis. The DON acknowledged the risks associated with antipsychotic medications, including their potential use as chemical restraints and the associated side effects. Despite the pharmacy's recommendations and the facility's policy, the physician did not provide a justification for disagreeing with the recommendations, leading to a deficiency in the facility's medication management practices.
Deficiency in Hemodialysis Record-Keeping
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident receiving hemodialysis. Specifically, the facility did not place resident-identifying information on 5 out of 17 Hemodialysis Communication forms in the Dialysis Communication Binder. This omission could lead to inadequate monitoring and inaccurate records, as the forms were not properly labeled and could not be scanned into the resident's electronic chart as part of her permanent record. The resident in question, a female with multiple diagnoses including dementia, end-stage renal disease, and severe cognitive impairment, was dependent on hemodialysis three times a week. Her care plan included specific interventions for monitoring her condition pre- and post-dialysis, such as checking the dialysis shunt for bleeding and infection. However, during an observation, it was noted that the resident returned from dialysis with bandages on her arm, which she indicated were applied at the facility, not the dialysis center, suggesting a lapse in following the facility's policy for post-dialysis care. Interviews with the facility's ADON and DON revealed that they were unaware of why the communication forms lacked resident names and were not scanned into the resident's chart. The ADON acknowledged that the absence of names on the forms was problematic, as it hindered proper documentation and record-keeping. The facility's policy on hemodialysis catheter care did not address documentation of pre/post-dialysis assessments, contributing to the deficiency in maintaining accurate clinical records.
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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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