Valley Grande Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Weslaco, Texas.
- Location
- 1212 S Bridge, Weslaco, Texas 78596
- CMS Provider Number
- 455621
- Inspections on file
- 37
- Latest survey
- March 23, 2026
- Citations (last 12 mo.)
- 42 (1 serious)
Citation history
Health deficiencies cited at Valley Grande Manor during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, including dementia and schizoaffective disorder, experienced a change in condition with shortness of breath and was moved overnight to a secured unit for closer monitoring. Record review showed no consent form for this placement, despite facility policy requiring consent for admission to the secured/locked area. In interviews, an LVN confirmed that consent is required for secured unit placement, and the DON acknowledged that no consent was obtained for this resident and that this was against the resident’s rights.
A resident with dementia and multiple comorbidities, but no documented psychosis or behavioral symptoms, was moved from her regular room to a secured unit for closer monitoring after an episode of shortness of breath, without a physician order and despite not meeting the facility’s written secured unit admission criteria. Staff, including LVNs and the DON, reported that the move was made at night for observation because more staff were present in the secured unit, and the resident was returned to her original room the following morning. The DON acknowledged that shortness of breath is not a criterion for secured unit placement and that the unit is intended for residents with behavioral issues, while the facility’s criteria require cognitive impairment plus assessment of high-risk behaviors such as self-harm or harm to others, which were not documented for this resident.
A resident with severe cognitive impairment, anxiety disorder, and multiple comorbidities was receiving Lorazepam for anxiety, wearing a Wander Guard, and had recently been placed in a secured unit for closer monitoring after an episode of shortness of breath requiring oxygen. Although these treatments and safety measures were documented in orders and on the MDS, the comprehensive person-centered care plan did not include any focus, goals, or interventions related to the Lorazepam, the Wander Guard, or the secured unit placement. The MDS nurse and DON acknowledged awareness of these needs and their responsibility for care plan updates, but the care plan was not revised in accordance with facility policy requiring ongoing assessment and measurable objectives and timeframes.
A resident with dementia, schizoaffective disorder, liver cirrhosis, and a severely impaired BIMS score was temporarily moved to a secured unit for closer monitoring after an episode of shortness of breath without a written, signed, and dated physician order, despite facility policy requiring such an order for secured unit placement. Nursing staff reported that the DON directed the transfer to and from the secured unit and confirmed no physician order was obtained, while also expressing uncertainty about order requirements for a Wander Guard. Record review corroborated the absence of an order for the secured unit placement, and the facility’s wandering and elopement policy lacked specific criteria for Wander Guard implementation.
A resident with severe cognitive impairment and multiple comorbidities, including dementia and liver cirrhosis, was observed with a Wander Guard on her wrist and had been moved to a secured unit after an episode of shortness of breath requiring oxygen and closer monitoring. Staff, including an LVN and the DON, were aware of the Wander Guard and the transfer to the secured unit, but the medical record contained no progress notes or change-in-condition entries documenting the initiation of the Wander Guard or the resident’s placement in the secured unit, despite facility policy requiring documentation of such changes and treatments.
A resident with vascular dementia and severe cognitive impairment, who required significant assistance with ADLs, gave $40.00 from his safe to a housekeeping staff member, who only returned $10.00 and used the remainder for personal expenses. The resident later reported the partial repayment, and the staff member admitted to receiving the money. This conduct occurred despite a facility policy stating residents must be free from misappropriation of property and exploitation.
A resident with Alzheimer's disease and vascular dementia, with severely impaired cognition, was maintained on olanzapine 10 mg twice daily with the sole documented indication of Alzheimer's disease and no end date. The e‑MAR confirmed ongoing administration, and the care plan only directed staff to monitor for side effects and effectiveness. The pharmacist and ADON both stated that Alzheimer's disease alone is not an appropriate diagnosis for antipsychotic use and that such use could cause death, while the DON acknowledged the order was continued as received from the hospital. The facility’s policy required that antipsychotics for dementia be used only after other potential causes of behavioral symptoms were identified and addressed, but the record contained no such documented indication.
Surveyors found a wound care medication cart left unlocked and unattended outside a room. An LVN responsible for the cart acknowledged she forgot to lock it and confirmed she was expected to secure the cart whenever she walked away, as residents could access medications not intended for them. The DON confirmed this expectation and stated that residents or visitors could grab medications and be harmed. Facility policy required all drugs and biologicals to be stored securely, with all compartments locked when not in use and medication carts never left unattended while unlocked.
The facility did not ensure that MDS assessments accurately reflected the status of three residents, omitting documentation of falls with injuries, physical aggression, delusions, and refusal of care. These omissions were identified through observations, interviews, and record reviews.
A resident with severe cognitive impairment and a high risk for falls experienced multiple falls, but the care plan did not include the use of a fall mat, even though one was observed in use. Facility leadership confirmed that the fall mat should have been documented in the care plan to ensure staff awareness and consistent implementation, as required by facility policy.
Two residents experienced incomplete and inaccurate medical record documentation after incidents involving a fall and aggressive behavior. Nursing staff failed to complete required change of condition forms, did not document timely notification of medical providers, and recorded vital signs and other data that did not correspond to the actual events. These actions were not in line with facility policy or accepted professional standards.
A deficiency was found when a CNA failed to follow infection control protocols by reusing disposable cleansing wipes multiple times during incontinent care for a resident with complex medical needs. Staff interviews revealed inconsistent understanding of proper wipe usage, and facility policy required single-use disposal to prevent cross-contamination. The observed practice did not align with established infection prevention procedures.
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.
A resident with severe cognitive impairment and left-sided paralysis, who was care planned for two-person assistance with transfers and showers, was left unattended in a shower chair by a single CNA. The CNA turned away to retrieve a mechanical lift, during which the resident fell and sustained acute fractures to the right great toe and first metatarsal, as well as a laceration. Staff interviews confirmed that the required two-person assistance was not provided, and the incident was not reported as neglect despite facility policy.
A resident with severe cognitive and physical impairments, dependent on two staff for bathing and transfers, was left in the care of a single CNA who attempted to transfer her alone, resulting in a fall and multiple injuries. The care plan's requirements for two-person assistance and use of a mechanical lift were not followed, and staff interviews confirmed that this was not an isolated incident due to staffing shortages. No documentation of required in-service training or a care plan policy was provided.
A resident with severe cognitive impairment and multiple medical conditions, who was care planned for two-person assistance with transfers, was left unattended in a shower chair by a single CNA. The resident fell and sustained acute fractures to the right great toe and first metatarsal. Staff interviews revealed the CNA was aware of the two-person assist requirement but proceeded alone due to staffing shortages, and there was a lack of clarity regarding abuse and neglect reporting procedures. The facility did not document in-service training or report the incident as neglect, despite policies requiring such actions.
A resident with severe cognitive and physical impairments, dependent on a two-person assist and mechanical lift for transfers, sustained a fractured toe and lip laceration after a fall during a transfer performed by a single CNA. The incident and a subsequent family allegation of neglect were not reported to the State Survey Agency within the required timeframe, despite facility policy and federal regulations mandating immediate reporting of such events.
A nurse failed to physically verify and account for a resident's prescribed morphine during a required narcotic count, instead relying on another nurse's statement about its location. The medication was later found to be missing, despite facility policy requiring both nurses to confirm the presence of all controlled substances at each shift change. The resident had severe cognitive impairment and multiple diagnoses, and the morphine had not been administered recently. Staff interviews and records confirmed the medication was present during previous counts but was unaccounted for during the shift involving the nurse who did not verify its presence.
A dietary aide entered the kitchen and handled snacks without wearing a required hairnet, in violation of facility policy. The aide, as well as dietary management, acknowledged the importance of hair restraints to prevent food contamination. This lapse placed all residents who receive meals from the kitchen at risk for food contamination.
A resident with a history of cerebral infarction and dysphagia experienced significant weight loss due to the facility's failure to accurately transcribe and initiate the correct enteral feeding order. The resident's feeding was supposed to be 65ml for 22 hours, but it was incorrectly entered as 65ml for 20 hours, leading to a 6-pound weight loss. The ADON admitted to the error and acknowledged the lack of formal training on accurate order documentation.
The facility failed to update care plans for two residents to include their skin conditions, specifically rashes, as identified in their assessments. Despite documentation of these conditions in medical records, the care plans lacked this information, potentially risking appropriate treatment. Interviews with staff revealed a lack of awareness and understanding of the facility's care plan policy, contributing to this oversight.
A resident with Alzheimer's and other conditions had a rash documented by the NP, but the LVN and ADON failed to record it in skin assessments, contrary to facility policy. Despite training, their documentation was incomplete, risking errors in care.
The facility failed to maintain a safe and sanitary emergency water supply, storing it in a non-air-conditioned warehouse 0.2 miles away. Observations revealed dusty jugs, some without caps, and makeshift coverings. Staff interviews showed a lack of awareness and responsibility for the water supply's condition, contrary to the facility's policy.
The facility failed to ensure that three residents' OOH-DNR forms were completed correctly, with missing physician and witness signatures, risking unwanted resuscitation. Interviews with staff revealed inconsistencies in the process of verifying and completing these forms, indicating a systemic issue in handling advance directives.
The facility failed to maintain accurate calibration logs for blood glucose meters, affecting 25 insulin-dependent residents. Missing logs across various wings indicated a systemic issue, despite staff awareness of the importance of calibration. This deficiency could lead to inaccurate glucose readings, compromising resident care.
A facility failed to notify a resident's representative and the Ombudsman in writing about a hospital transfer due to critical potassium levels. The resident had Alzheimer's, encephalopathy, pneumonia, and Type 2 Diabetes Mellitus. Staff interviews revealed that notifications were made via phone, not in writing, contrary to policy.
A facility failed to provide a written notice of the bed-hold policy to a resident and their representative during a hospital transfer. The resident, with multiple diagnoses, was transferred due to critical potassium levels, but neither the resident nor their representative received the required written information. Interviews with staff revealed that the facility communicated verbally, contrary to their policy requiring written notification.
A facility failed to include a continuous oxygen order in a resident's care plan, despite the resident's need for oxygen due to chronic obstructive pulmonary disease. Observations confirmed the resident was using oxygen, but the care plan did not document this requirement. Interviews with nursing staff could not confirm any negative outcomes from this oversight.
Two residents in the facility received oxygen therapy at levels inconsistent with physician orders. One resident with COPD was given 2.5 Lpm instead of the prescribed 2.0 Lpm, while another resident with multiple health issues received 4 Lpm instead of 2 Lpm. Staff acknowledged the discrepancies, noting potential risks, but no immediate negative effects were observed.
Two residents with severe cognitive impairment received inadequate perineal care from CNAs, who failed to clean properly and sanitize hands between glove changes. Despite training, the CNAs admitted to lapses, and the DON could not provide recent infection control training documentation.
A resident with Alzheimer's and dementia eloped from the facility undetected on the day of admission, spending the night outside in a nearby church's backyard. The facility failed to provide adequate supervision and did not secure a side door without an alarm, leading to the resident's elopement and subsequent hospitalization.
A resident with severe impaired cognition received an antipsychotic medication (Nuplazid) without the necessary informed consent. Despite the facility's policy, the responsible party had not signed the consent form before the medication was administered. Interviews with staff revealed delays in obtaining signed consents, placing the resident and others at risk.
A resident with multiple medical conditions was left dangling above her bed when the straps of a Hoyer lift tore during a transfer. The incident was not reported or investigated by the facility, despite the resident's fear and potential for harm. Interviews revealed inconsistencies and a lack of proper reporting and investigation, violating the facility's policy on abuse, neglect, and exploitation.
The facility failed to report alleged neglect and injuries involving a resident within the required timeframe. Incidents included an unwitnessed fall resulting in a laceration and fracture, unexplained redness on the forehead and eyelid, and a delayed report of an injury of unknown origin. The resident had severe cognitive impairment and multiple diagnoses, and the facility did not follow its policy on timely reporting.
A resident experienced a frightening incident during a transfer using a Hoyer lift when the loops on the straps tore, leaving her dangling above her bed. The incident was not reported or investigated as required by the facility's policy, and the torn sling was discarded without examination. Interviews revealed inconsistencies in the understanding and reporting of the incident, and the facility's failure to investigate properly placed the resident and others at risk.
Failure to Obtain Required Consent for Temporary Secured Unit Placement
Penalty
Summary
The facility failed to obtain required consent before placing a resident in a secured unit, thereby not ensuring the resident was fully informed and understood the care and treatment to be furnished. The resident was an older female with a history of liver cirrhosis, TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension, originally admitted in 2022 and readmitted in 2025. Record review on 03/20/26 showed no consent form for placement into the secured unit. The facility’s Secured Unit Admission Criteria, dated 3/2026, specified that consent must be received for placement in the secured/locked area. According to progress notes dated 03/11/26, the resident experienced a change in condition with shortness of breath. In interviews, LVN B stated the resident was placed in the secured unit the prior week because she needed close monitoring after an episode of shortness of breath requiring oxygen, and confirmed that consent is required when a resident is placed in the secured unit. The DON reported that the resident was moved to the secured unit on the night of 03/11/26 for closer monitoring due to the change in condition and that there were more staff available in that unit. The DON acknowledged that a consent was required for any secured unit placement, that no consent was obtained for this resident even though she remained there only overnight, and stated she did not know why consent was not obtained and that this was against the resident’s rights.
Inappropriate Placement of Resident in Secured Unit Without Meeting Criteria or Physician Order
Penalty
Summary
The facility failed to protect a resident from involuntary seclusion when the resident was placed in a secured unit without meeting the unit’s admission criteria and without a physician order. The resident was an elderly female with liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension. Her most recent MDS showed a BIMS score of 4, indicating severely impaired cognition, but documented no hallucinations, delusions, or behavioral symptoms directed toward others. Record review of the order summary for the relevant date showed no order for the resident to be placed in the secured unit. According to staff interviews, the DON directed that the resident be moved to the secured unit late at night due to an episode of shortness of breath, stating that there were more staff available there to monitor her. The usual nurse for the secured unit reported that the resident had been placed there the prior week for closer monitoring after shortness of breath, and that the DON handled the placement. Another LVN stated that the resident had been in her regular room without issues one day and was in the secured unit the next morning, and that she was later directed by the DON to return the resident to her original room. The DON acknowledged that shortness of breath is not a criterion for secured unit placement and that the unit’s criteria require behavioral issues, while the facility’s written secured unit admission criteria require cognitive impairment and assessment of high-risk behaviors such as self-harm or harm to others. The resident did not have documented behavioral issues meeting these criteria.
Failure to Update Person-Centered Care Plan for Psychotropic Use, Wander Guard, and Secured Unit Placement
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple medical and psychiatric diagnoses, including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension. The resident’s quarterly MDS showed severely impaired cognition (BIMS score of 4), an active diagnosis of anxiety disorder, use of an antianxiety medication, and the presence of a wander/elopement alarm. Record review showed an active order for Lorazepam 0.5 mg twice daily for anxiety and confirmed that the resident wore a Wander Guard device. However, the resident’s care plan, initiated months earlier, contained no focus, goals, or interventions related to Lorazepam use, the Wander Guard, or the resident’s placement in a secured unit. Interviews with staff confirmed awareness of these treatments and safety measures but also confirmed that they were not incorporated into the care plan. The MDS nurse acknowledged knowing the resident was taking Lorazepam and wearing a Wander Guard, had documented the Wander Guard on the MDS, and stated that both the medication and device should have been added to the care plan but were not. The LVN assigned to the secured unit reported that the resident had been placed in the secured unit the prior week for closer monitoring after an episode of shortness of breath requiring oxygen and stated that care plan updates were the responsibility of the MDS nurse or DON. The DON confirmed shared responsibility with the MDS nurse for implementing and revising care plans, acknowledged awareness of the resident’s Lorazepam use, Wander Guard, and recent placement in the secured unit for closer monitoring, and stated that these changes should have been added to the care plan but were not, despite a facility policy requiring ongoing assessment and revision of care plans as resident conditions change.
Failure to Obtain Physician Order for Temporary Secured Unit Placement
Penalty
Summary
The deficiency involves the facility’s failure to obtain a written, signed, and dated physician order for a resident’s placement in a secured unit, as required by facility policy. Record review showed that a female resident with diagnoses including liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension, and a severely impaired BIMS score of 4, had no physician order dated 03/11/26 for placement in the secured unit on her Order Summary Report. The resident’s admission record reflected an original admission date of 12/06/22 and a readmission date of 08/01/25. The facility’s Secured Unit Admission Criteria, dated 3/2026, specified that a physician order for placement would be obtained for secured unit placement. Interviews confirmed that the resident was moved to the secured unit without a physician order. LVN B, the usual nurse for the secured unit, stated the resident was placed there the prior week for closer monitoring after an episode of shortness of breath and that the DON handled the placement; LVN B was unsure whether an order was required for a Wander Guard. LVN D reported that the resident was in her regular room on one day and in the secured unit the next morning, and that she was told in report the resident had shortness of breath overnight and was placed in the unit for closer observation, then later directed by the DON to return the resident to her room. The DON stated the resident was placed in the secured unit around 11:00 p.m. and returned to her room the following morning, acknowledged there was no physician order for the placement despite policy requiring one, and stated she did not know why she had not obtained the order. Review of the facility’s Wandering and Elopements Policy showed no criteria or implementation guidance for the use of a Wander Guard.
Failure to Document Wander Guard Use and Secured Unit Placement
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident in accordance with accepted professional standards and its own Charting and Documentation policy. A female resident with liver cirrhosis, history of TIA, dementia, schizoaffective disorder, depression, anxiety, and hypertension had a severely impaired cognition score (BIMS of 4) and was identified on the MDS as having a wander/elopement alarm. On observation, a Wander Guard was noted on her right wrist, and staff, including an LVN and the DON, acknowledged awareness that the device was in place. However, record review showed no progress note or change in condition entry documenting when or why the Wander Guard was initiated, who placed it, or any associated assessment, despite the facility policy requiring documentation of changes in condition and procedures/treatments with date, time, provider, and assessment details. The facility also failed to document the resident’s placement in a secured unit. An LVN assigned to the secured unit reported that the resident had been moved there the previous week because she experienced shortness of breath and required oxygen and closer monitoring, and stated that the DON handled the placement. The DON confirmed that the resident had been placed in the secured unit due to an episode of shortness of breath and the need for closer monitoring and more staff presence. Despite these changes in the resident’s status and location, the resident’s medical chart contained no progress note or change in condition entry reflecting the transfer to the secured unit, contrary to the facility’s policy that all nurses should update the medical record to reflect new conditions and changes in the resident’s status.
Failure to Prevent Misappropriation of Resident Funds by Housekeeping Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation and exploitation of property by allowing a housekeeping staff member to obtain money from the resident for the staff member’s own personal use. The resident was an elderly male with vascular dementia, severe cognitive impairment as evidenced by a BIMS score of 4, and care plan documentation of impaired cognitive function and thought processes. He required supervision or touching assistance with eating and substantial/maximal assistance with toileting and bathing. Despite these cognitive and functional limitations, the resident reported that he had given $40.00 from his safe to a housekeeping employee, who only returned $10.00. The resident stated that no staff had stolen from him and that he felt safe, but he acknowledged that he had given the housekeeping staff member money and had not been fully repaid until later. The administrator later confirmed that the resident had informed him that he lent $40.00 to the housekeeping staff member, who had only repaid $10.00 at that time, and that the staff member admitted to receiving the money. The facility’s own Abuse Prevention Program policy stated that residents have the right to be free from misappropriation of resident property and exploitation, yet the incident occurred when the housekeeping staff member accepted and used the resident’s money for personal expenses.
Inadequate Indication for Antipsychotic Use in Dementia Patient
Penalty
Summary
The facility failed to ensure a resident was free from chemical restraints that were not required to treat a medical symptom by administering the antipsychotic medication olanzapine (Zyprexa) without an adequate clinical indication. The resident was an elderly male with diagnoses of Alzheimer's disease and vascular dementia, and an MDS assessment showed a BIMS score of 3, indicating severely impaired cognition. The resident’s care plan and physician’s order documented the use of olanzapine 10 mg orally twice daily with the indication listed only as "Alzheimer's disease, unspecified," and the order did not include an end date. The MDS identified the resident as receiving a high‑risk antipsychotic, and the care plan interventions were limited to monitoring for side effects, effectiveness, and adverse reactions every shift. Record review of the e‑MAR showed that olanzapine 10 mg was administered over the reviewed period. During interviews, the pharmacist stated that Alzheimer's disease was not an appropriate diagnosis for an antipsychotic medication and that use of an antipsychotic in a resident with Alzheimer's disease could cause death. The ADON similarly stated that ordering an antipsychotic for Alzheimer's disease could cause death and was not recommended for residents with Alzheimer's or dementia. The DON confirmed the resident was on olanzapine and read the order from the computer, acknowledging that the indication of Alzheimer's disease was allowed because the resident came from the hospital with that order. The facility’s own antipsychotic medication use policy stated that antipsychotic medications may be considered for residents with dementia only after medical, physical, functional, psychological, emotional, psychiatric, social, and environmental causes of behavioral symptoms have been identified and addressed, but the documentation reviewed did not show such an indication or assessment beyond the Alzheimer's diagnosis.
Unlocked and Unattended Wound Care Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to medication storage and security when a wound care medication cart was observed left unlocked and unattended outside a resident room. During the observation, the LVN responsible for the wound care cart exited the room, and the surveyor informed her that the cart was unlocked; the LVN then locked the cart. The cart contained drugs and biologicals and was required by facility policy to be locked when not in use and never left unattended while unlocked. In an interview, the LVN acknowledged she was responsible for the wound care cart and stated she was expected to lock it when walking away, explaining that she had left it unlocked because she forgot. She further stated that if the cart was left unlocked, a resident could open a drawer and take items not intended for them. In a separate interview, the DON confirmed the expectation that staff lock medication carts when they walk away and stated that a resident or visitor could grab medication from an unlocked cart and be harmed. Review of the facility’s undated “Storage of Medications” policy showed that all drugs and biologicals must be stored in a safe, secure manner, with all compartments containing medications locked when not in use and medication carts not left unattended while unlocked.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status of three residents. For one resident, the quarterly MDS assessment did not document three separate falls, each resulting in varying degrees of injury, that occurred on specific dates. Another resident's quarterly MDS assessment omitted documentation of an incident involving physical aggression. Additionally, a third resident's quarterly MDS assessment failed to record behaviors such as delusions, refusal of care, and a fall that resulted in minor injury. These omissions were identified through observations, interviews, and record reviews, indicating that the assessments did not accurately capture the residents' conditions and events as required.
Failure to Include Fall Mat Intervention in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, generalized muscle weakness, lack of coordination, mood disorder, type 2 diabetes, and chronic kidney disease. The resident was identified as high risk for falls, with a fall risk evaluation score of 13 and a BIMS score of 2 indicating severe cognitive impairment. Despite a history of multiple falls resulting in injuries such as a laceration to the back of the head and a skin tear, the care plan did not include the use of a fall mat, even though one was observed in place next to the resident's bed. The care plan interventions focused on call light accessibility, appropriate footwear, monitoring for pain or injury, therapy evaluation, and offering activities, but omitted documentation of the fall mat as an intervention. Interviews with facility leadership, including the ADON and DON, revealed uncertainty about whether the fall mat was in use and acknowledged that if it was being used, it should have been included in the care plan to ensure staff awareness and consistent implementation. The facility's policy required that care plans incorporate identified problem areas and be revised as residents' conditions change, but this was not followed in the case of the fall mat intervention for this resident. The omission of the fall mat from the care plan was identified through observations, interviews, and record review.
Incomplete and Inaccurate Documentation of Resident Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. In one instance, a nurse did not document a resident's change of condition following an incident where the resident was found on the floor. Although the nurse assessed the resident and notified the responsible party, she did not complete a change of condition form, did not document notification of the nurse practitioner, and did not perform a fall risk evaluation or neuro checks. The nurse relied on another resident's account that the individual was crawling, and therefore did not consider it a fall, despite not witnessing the event herself. The nurse also could not recall if any orders were given by the nurse practitioner. For another resident, there were multiple documentation failures related to incidents of aggressive behavior and a fall. The change of condition form for the aggressive behavior was completed and signed by the DON several days after the incident, with vital signs and other information recorded for a later date rather than at the time of the event. Similarly, the change of condition form for the fall included vital signs and blood glucose readings from dates that did not correspond to the incident, including a blood glucose value from two years prior. The primary nurse did not complete the required documentation at the time of the incidents, and the DON later completed some of the forms after the fact. Interviews with facility staff, including the ADON and DON, confirmed that the nurses involved had been trained on proper documentation procedures, including the need to complete change of condition forms, risk assessments, and to notify appropriate parties. The facility's own policy required that all incidents, accidents, or changes in condition be recorded in the resident's medical record, including notification of family and physicians. Despite this, the required documentation was not completed at the time of the incidents, resulting in incomplete and inaccurate medical records for the residents involved.
Improper Reuse of Disposable Wipes During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection control practices during incontinent care for a male resident with significant medical needs, including type 2 diabetes, muscle weakness, dementia, bowel incontinence, and an indwelling catheter. During the observed care, the CNA used the same disposable cleansing wipe multiple times on different areas, crumpling and reusing the wipe instead of discarding it after a single use. This practice was observed repeatedly throughout the procedure, including care of the genital and buttock areas. Interviews with staff revealed inconsistent understanding and application of infection control protocols. The CNA involved stated that facility training allowed for folding and reusing wipes as long as a clean area was used, while another CNA and an LPN both indicated that wipes should be used once and then discarded to prevent cross-contamination. The Assistant Director of Nursing (ADON) acknowledged that best practice was to use one wipe per swipe and dispose of it, but also described some ambiguity in staff training regarding the reuse of wipes if a clean area remained. Review of the facility's policies and competency assessments confirmed that disposable items should be discarded after use, and FDA guidance also supports immediate disposal of used wipes to prevent cross-contamination. Despite regular in-service training and competency checks, the observed practice did not align with facility policy or best practice, resulting in a failure to maintain an effective infection prevention and control program for residents requiring incontinent care.
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 Provide Required Two-Person Assistance Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, stroke, and left hemiplegia, who was care planned as dependent on two staff for transfers and showers, was left unattended in a shower chair by a single CNA. The resident required a mechanical lift with two-person assistance for transfers, as documented in her care plan and MDS. Despite these requirements, the CNA attempted to manage the transfer alone and turned away to retrieve the mechanical lift, during which time the resident fell from the shower chair. The fall resulted in the resident sustaining acute fractures to the right great toe and first metatarsal, as confirmed by x-ray, and a laceration to the top lip. The resident experienced pain requiring PRN analgesics and a new order for tramadol, as well as a referral to orthopedics. The incident was witnessed, and the CNA involved acknowledged that she was alone with the resident, despite knowing the resident was a two-person assist, and attributed this to staffing shortages at the time. Interviews with staff confirmed that the facility's policy and the resident's care plan required two-person assistance for transfers and use of the mechanical lift. The CNA admitted to performing two-person assists alone on several occasions due to short staffing. There was no documentation of in-service training following the incident, and the fall was not reported as neglect, despite facility policy and regulatory definitions that classify such failures to provide necessary services as neglect.
Failure to Implement Two-Person Assist for Dependent Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant cognitive and physical impairments. The resident, an elderly female with diagnoses including dementia, stroke with left hemiplegia, diabetes, epilepsy, and hypertension, was assessed as having severe cognitive impairment and was dependent on two staff members for bathing and transferring, as documented in her care plan and MDS assessments. Despite these documented needs, the care plan contained inconsistencies regarding the level of assistance required for bathing, and interventions were not consistently implemented as specified. On the day of the incident, a CNA provided a shower to the resident alone, despite the care plan indicating a two-person assist and the use of a mechanical lift for transfers. The CNA attempted to transfer the resident from the shower chair to the bed without assistance, during which the resident fell and sustained acute fractures to her right foot and a laceration to her lip. The CNA later stated that due to staffing shortages, she had performed two-person assists alone on several occasions, and acknowledged the risks involved. There was no documentation of any in-service training the CNA claimed to have received following the incident. Interviews with other staff confirmed that the expectation was for two staff to assist with such transfers, and that failure to do so could result in injury. The DON was not present at the time of the incident but reviewed the notes afterward. The facility did not provide a care plan policy when requested. The failure to implement the care plan as written, specifically regarding the required level of assistance for bathing and transferring, directly led to the resident's fall and injuries.
Failure to Implement Abuse and Neglect Policies Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically for a resident with severe cognitive impairment and multiple medical conditions, including dementia, stroke, diabetes, epilepsy, and hypertension. The resident was care planned as dependent on two staff for transfers and required a mechanical lift with two-person assistance. Despite these documented needs, the resident was left in a shower chair with only one CNA present, who turned away to retrieve the mechanical lift, leaving the resident unattended. During this time, the resident fell from the shower chair and sustained acute fractures to the right great toe and first metatarsal, as confirmed by x-ray. Progress notes documented the resident's pain and subsequent administration of pain medication, as well as a referral to orthopedics. Interviews with staff revealed that the CNA was aware the resident required two-person assistance but proceeded alone due to staffing shortages. The CNA also reported having to perform two-person assists alone on several occasions. Further interviews indicated a lack of clarity among staff regarding abuse and neglect reporting procedures, and there was no documentation of in-service training following the incident. The facility's policies defined neglect as the failure to provide necessary goods or services to avoid harm, and provided an example similar to the incident that occurred. The facility did not report the fall as neglect, nor did it provide immediate in-service training to address the deficiency.
Failure to Timely Report Fall with Injury and Alleged Neglect
Penalty
Summary
The facility failed to ensure timely reporting of alleged neglect and a fall with injury involving a resident with severe cognitive impairment and significant physical limitations. The resident, who required a two-person assist and mechanical lift for transfers due to dementia, stroke, and hemiplegia, experienced a fall while being transferred by a single CNA, contrary to her care plan. The fall resulted in a fractured right great toe and a laceration to the lip, with subsequent pain requiring medication and orthopedic referral. Following the incident, the resident's family member alleged neglect, expressing concern that such accidents should not occur under 24-hour facility care. The allegation was communicated to facility staff, but the incident and the neglect allegation were not reported to the State Survey Agency within the required timeframe. Facility policy and federal regulations mandate immediate reporting of such incidents, especially when they involve potential neglect or result in serious injury. However, the facility did not notify the State Survey Agency within two hours of the incident or within 24 hours for the neglect allegation, as required. Interviews with staff revealed confusion and inconsistency regarding the reporting requirements and the circumstances of the fall. The CNA involved admitted to performing a two-person assist transfer alone due to staffing shortages, acknowledging that this practice increased the risk of resident falls. Despite the family member's initial allegation of neglect, the administrator did not report the incident, citing the family member's later recantation. The facility's failure to report both the fall with injury and the neglect allegation constituted a deficiency in meeting regulatory requirements for timely reporting of suspected abuse, neglect, or injury.
Failure to Accurately Account for Controlled Substance During Narcotic Count
Penalty
Summary
A deficiency occurred when a nurse failed to properly verify and account for a resident's controlled medication, specifically Morphine Sulfate Oral Solution, during a required narcotic count. The nurse, LVN C, signed off on the narcotic count based on another nurse's statement that the medication was in the refrigerator, without physically checking or confirming its presence. Subsequent review and interviews revealed that the morphine was missing and could not be located, despite being required to be stored in a double-locked medication cart and included in the shift-to-shift narcotic count. The resident involved was an elderly female with multiple diagnoses, including severe cognitive impairment, polyosteoarthritis, osteomalacia, and dementia. She had a physician's order for morphine to be administered as needed for pain, but her pain assessment at the time indicated no pain. The last documented administration of the morphine was several days prior to the incident. The facility's narcotic count records and staff interviews confirmed that the medication was present during previous counts, but was unaccounted for during the shift change involving LVN C. Interviews with nursing staff and review of facility policy confirmed that the standard procedure required both the oncoming and outgoing nurses to physically verify and count all controlled substances at each shift change. The failure to follow this procedure by not physically verifying the presence of the morphine led to the medication being unaccounted for. The incident was reported to the Director of Nursing, and the missing medication was not found despite a search. The facility's policy and staff statements emphasized the importance of accurate narcotic counts to ensure all medications are accounted for at all times.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
Dietary Aide A entered the facility's only kitchen to retrieve snacks without wearing a hairnet, as observed by surveyors. During interviews, Dietary Aide A admitted to forgetting to wear the required hairnet due to being late and acknowledged awareness of the policy and the potential for food contamination if hair is not properly restrained. The Dietary Manager (DM) and Assistant Dietary Manager (ADM) both confirmed that all staff are required to wear hairnets in the kitchen to prevent food contamination, and that this requirement is regularly communicated to staff during meetings. A review of the facility's Food Preparation and Service policy, revised in April 2019, confirmed that food and nutrition services employees are required to wear hair restraints to prevent hair from contacting food. The failure to follow this policy placed all 92 residents who receive meals from the kitchen at risk for food contamination and foodborne illness, as the kitchen is the sole source of meal preparation and distribution in the facility.
Failure to Accurately Transcribe Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. The resident, a female with a history of cerebral infarction, dysphagia, gastrostomy status, and type 2 diabetes mellitus, experienced a significant weight loss due to the facility's failure to transcribe and initiate the correct enteral feeding order. The resident's feeding order was supposed to be 65ml for 22 hours, but it was incorrectly entered as 65ml for 20 hours, leading to a 6-pound weight loss over a two-month period. The deficiency was identified through interviews and record reviews, which revealed that the dietary recommendation for the resident's feeding was agreed upon by the physician assistant but was not accurately reflected in the physician orders. The Assistant Director of Nursing (ADON) admitted to inputting the order incorrectly and acknowledged that the error was due to not double-checking the entry. The ADON also stated that the error was brought to her attention in December, at which point the order was corrected. The facility's policy on charting and documentation requires that medical records be complete and accurate, but this was not adhered to in this case. The ADON and the Director of Nursing (DON) were responsible for monitoring and ensuring orders were correctly input, but the ADON admitted to not having formal training on weights and accurate order documentation, relying instead on on-the-job training. This lack of accurate documentation and monitoring led to the resident not receiving the necessary nutritional intake, resulting in weight loss.
Failure to Update Care Plans with Skin Conditions
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for two residents, which included measurable objectives and timeframes to address their medical, nursing, and psychosocial needs. Specifically, the care plans for two residents did not include documentation of their skin conditions, namely rashes, which were identified in their comprehensive assessments. This oversight could potentially place residents at risk for not receiving appropriate treatment and services. For one resident, the facility's records indicated a history of Alzheimer's disease, anxiety disorder, dysphagia, and polyneuropathy. Despite multiple nurse practitioner notes documenting a generalized scattered rash and a psoriatic rash over several months, the resident's care plan did not include any mention of these skin conditions. The MDS nurse, responsible for updating care plans, was unaware of the resident's rash and acknowledged that the care plan was not updated properly. Another resident, with diagnoses including parkinsonism, peripheral vascular disease, chronic kidney disease, vascular dementia, type 2 diabetes mellitus, and hemiplegia, also had a rash documented in their medical records. A change in condition noted by the wound care nurse indicated a new onset rash, yet the care plan did not reflect this condition. Interviews with facility staff, including the MDS nurse, ADON, and LVN, revealed a lack of awareness and understanding of the facility's care plan policy, contributing to the failure to update the care plans accurately.
Failure to Document Resident's Rash in Skin Assessments
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident, specifically regarding the documentation of a skin rash. The resident, an elderly female with Alzheimer's disease, anxiety disorder, dysphagia, and polyneuropathy, was noted to have a generalized scattered rash by the Nurse Practitioner (NP) on multiple occasions. However, the skin observation tools completed by the Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) did not document the presence of this rash, despite the facility's policy requiring comprehensive skin assessments. Interviews with the LVN and ADON revealed that they were responsible for completing the skin assessments but failed to document the rash observed by the NP. The LVN admitted to possibly overlooking the rash and stated that she was not notified of it during her assessments. The ADON also did not recall the rash during her assessments and suggested that the omission might have been due to copying previous assessments or focusing on more acute issues. Both staff members acknowledged the importance of accurate documentation for ensuring appropriate treatment and compliance with facility policy. The facility's policy on charting and documentation emphasized the need for objective, complete, and accurate records. Despite training sessions on skin assessments, the LVN and ADON did not adhere to these standards, resulting in incomplete documentation of the resident's condition. This deficiency in record-keeping could potentially affect the care and treatment of residents by leading to errors or delays in addressing their medical needs.
Inadequate Emergency Water Supply Storage
Penalty
Summary
The facility failed to ensure that an adequate emergency water supply was readily available and stored in a safe and sanitary manner. The emergency water supply was stored in a warehouse-type building located 0.2 miles from the facility, which lacked air conditioning and had vent openings to the outside. During an observation, surveyors noted that the water jugs were dusty, some jugs lacked caps, and others had makeshift coverings such as paper napkins secured with rubber bands. The storage conditions did not comply with the facility's policy, which required water to be stored in a cool, dark place. Interviews with facility staff revealed a lack of awareness and responsibility regarding the condition of the emergency water supply. The Maintenance Supervisor, who was responsible for checking the water supply every two months, was unaware of the missing caps and the unsanitary conditions. The Dietary Manager and the Administrator also did not know about the deficiencies in the water storage. The facility's policy, based on guidelines from the Federal Emergency Management Agency, was not followed, potentially placing residents at risk due to the possibility of contaminated water.
Incomplete DNR Forms Risk Residents' Wishes
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, specifically an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order, for three residents. For Resident #30, the OOH-DNR form was not completed correctly as the physician did not sign in the appropriate section, which is required to validate the document. This oversight could potentially lead to the resident receiving cardiopulmonary resuscitation (CPR) against their wishes. Similarly, Resident #3's OOH-DNR form was incomplete because the physician did not sign the section designated for two physicians to act on behalf of an adult who is incompetent or unable to communicate. This lack of a proper signature rendered the DNR form invalid, risking the possibility of unwanted resuscitation efforts. For Resident #57, the OOH-DNR form was missing a signature from the second witness in the required section. This omission also invalidated the DNR form, which could result in the resident being treated as a full code, contrary to their advance directive. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), the Director of Nursing (DON), and the Social Worker (SW), revealed a lack of consistent procedures and oversight in ensuring that DNR forms were completed and signed correctly, highlighting a systemic issue in the facility's handling of advance directives.
Failure to Maintain Accurate Glucometer Calibration Logs
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for 25 residents who were insulin-dependent, as evidenced by missing calibration logs for blood glucose meters. The absence of these logs spanned several dates across different wings of the facility, indicating a systemic issue in maintaining accurate records. The facility's policy required regular calibration checks to ensure the accuracy of blood glucose readings, but these were not consistently documented. Interviews with staff, including LVNs and the DON, confirmed that the night shift was responsible for these calibrations and logs, yet significant gaps in documentation were found. The lack of updated calibration logs could lead to inaccurate blood glucose readings, which are critical for managing insulin-dependent residents. The facility's policy and the Blood Glucose Monitoring System User's Guide both emphasize the importance of control solution testing to verify the accuracy of test results. Despite this, the facility did not adhere to these guidelines, potentially compromising the health and safety of the residents. Staff interviews revealed an awareness of the importance of calibration, but the execution was inconsistent, leading to the identified deficiency.
Failure to Notify Resident's Representative and Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify a resident's representative and the Office of the State Long-Term Care Ombudsman in writing about a transfer to the hospital. This deficiency was identified for one resident who was transferred due to critical potassium levels. The resident had a history of Alzheimer's disease, encephalopathy, pneumonia, and Type 2 Diabetes Mellitus. Despite the transfer, there was no documentation that the required notifications were made in writing, as mandated by the facility's policy. Interviews with facility staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Business Office Manager (BOM), revealed that the facility's practice was to inform the resident's representative via telephone rather than in writing. Additionally, the local Ombudsman confirmed that the facility was not sending notices of discharges or transfers. The facility's policy requires written notification to the resident's representative and the Ombudsman, including details about the transfer, appeal rights, and contact information for advocacy services.
Failure to Provide Written Bed-Hold Policy During Resident Transfer
Penalty
Summary
The facility failed to provide a written notice of the bed-hold policy to a resident and their representative during a transfer to the hospital. This deficiency was identified for one resident among four reviewed for transfers. The resident, who had diagnoses including Alzheimer's disease, encephalopathy, pneumonia, and Type 2 Diabetes Mellitus, was transferred to a hospital due to critical potassium levels. However, there was no documentation indicating that the resident or their representative received a written copy of the bed-hold policy at the time of transfer. Interviews with facility staff, including a Registered Nurse (RN), the Director of Nursing (DON), and the Business Office Manager (BOM), revealed that the facility did not provide written information about the bed-hold policy during transfers. The RN and DON stated that information was communicated verbally over the phone, and the BOM indicated that the nurses were responsible for providing such information. A review of the facility's policy on transfer or discharge notice confirmed that written notification, including the bed-hold policy, should be provided to residents and their representatives before or at the time of transfer.
Failure to Include Oxygen Order in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical and nursing needs. Specifically, the care plan did not reflect the resident's order for continuous oxygen at 2 liters per minute via nasal cannula. This oversight was identified during a review of the resident's records, which showed an indefinite order for oxygen that was not included in the care plan. Observations confirmed that the resident was using oxygen, but the care plan did not document this need. The resident, an elderly female with diagnoses including chronic obstructive pulmonary disease, transient ischemic attack, and hypertension, had a moderately intact cognitive status. Despite the presence of signage indicating oxygen use and the resident's acknowledgment of feeling better since being on oxygen, the facility's policy on comprehensive care plans did not mention the resident's oxygen order. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed they were unable to determine if the lack of care planning for the oxygen order resulted in any negative outcomes for the resident.
Failure to Adhere to Prescribed Oxygen Levels for Residents
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents who required oxygen therapy. Resident #40, a female with chronic obstructive pulmonary disease and other health issues, was observed receiving oxygen at 2.5 liters per minute (Lpm) via nasal cannula, contrary to the physician's order of 2.0 Lpm. Despite the discrepancy, staff members, including an LVN and the ADON, noted that there were no negative effects from the increased oxygen level. However, the failure to adhere to the prescribed oxygen level represents a deviation from the physician's orders. Similarly, Resident #3, who has multiple health conditions including Alzheimer's and congestive heart failure, was observed receiving oxygen at 4 Lpm instead of the ordered 2 Lpm. The resident was not in distress during observations, but the LVN responsible for the resident acknowledged the incorrect setting and noted that maintaining the higher oxygen level could lead to respiratory issues. The DON confirmed that nurses are responsible for checking oxygen settings every shift, but there was a lapse in ensuring the correct oxygen level was maintained for Resident #3. The facility's policy on oxygen administration requires verification of physician orders and adherence to prescribed treatments. However, the observations and interviews revealed that the oxygen settings for both residents were not consistent with the physician's orders, indicating a failure in following the facility's procedures for safe oxygen administration. This deficiency could potentially place residents at risk of respiratory complications, although no immediate negative outcomes were reported.
Inadequate Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper incontinent care practices observed for two residents. Resident #17, a male with severe cognitive impairment and multiple health conditions including Alzheimer's and chronic kidney disease, was not provided proper perineal care by CNA K. During an observation, CNA K did not clean the resident's penis, scrotum, and inner thighs adequately and failed to sanitize her hands between glove changes. Similarly, Resident #11, a female with severe cognitive impairment and various health issues such as heart failure and dementia, also received inadequate perineal care. CNA K used only one wipe to clean the resident's inner thighs and did not rinse or dry the perineal area. Both CNA K and CNA L failed to sanitize their hands between glove changes, which is a critical step in preventing infections. Interviews with the CNAs revealed that they were aware of the potential for infection due to their lapses in hand hygiene and perineal care. Despite having been trained and having competency checks, they admitted to forgetting key steps in the process. The Director of Nursing confirmed that CNAs have access to necessary supplies and are expected to follow proper procedures, but could not provide documentation of recent infection control training.
Resident Elopement Due to Inadequate Supervision and Unsecured Exit
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. Specifically, the facility did not provide adequate supervision to prevent a resident with Alzheimer's disease and dementia from eloping undetected. The resident was admitted to the facility and eloped on the same day, spending the night outside in the backyard of a nearby church before being found the next morning by police. The resident was taken to the hospital for evaluation after being found lethargic and shivering, having spent the night outside in the cold. The initial assessment of the resident indicated that he required limited assistance with bed mobility and transfers, but there was no indication of exit-seeking behavior. However, the facility did not complete a comprehensive assessment to identify potential exit-seeking tendencies. On the night of the incident, the resident was last seen walking in the facility's B wing north corridor. The staff initiated a search and notified the police, but the resident was not found until the next morning. The facility's investigation revealed that the resident likely exited through a side door that did not have an alarm, which was used by staff and residents to access the patio. Interviews with staff indicated that they were not aware of the resident's exit-seeking behavior and that the facility's elopement procedures were not effectively implemented. The facility's policy required staff to promptly report any resident suspected of being missing and to initiate a search of the building and premises. However, the staff did not have adequate information about the resident's potential exit-seeking behavior, and the side door without an alarm allowed the resident to exit the building undetected. The facility's failure to provide adequate supervision and secure the environment led to the resident's elopement and subsequent hospitalization.
Removal Plan
- The side door lock was changed; the dead bolt was replaced with a keypad, and a code alert was installed.
- All staff were in-serviced on the topic of elopement.
- All new admissions with diagnosis of dementia will need a wander guard.
- Nurses and CNAs are to do a walking round at the start and at the end of their shifts.
- The only door without an alarm was replaced with a magnetic lock with power supply, an all-weather keypad, and a 24V supply with back-up battery port.
- All residents who were at risk of wandering had a current face sheet and demographic information in the elopement binder.
- Maintenance Director tested all exit doors and ensured the alarm was activated if a resident with a wander guard tried to exit.
- Staff were in-serviced on the topics of facility policy and procedure related to identifying residents with exit seeking tendencies, redirecting, and the facility's code used for elopements.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment. Specifically, the facility did not ensure that consent forms were properly completed or signed by a responsible party before administering an antipsychotic medication (Nuplazid) to a resident. This resident, a female with severe impaired cognition, was given the medication without the necessary informed consent, which is a violation of resident rights and facility policy. The resident, who has diagnoses including dementia with behavioral disturbance, Parkinson's disease, heart disease, type 2 diabetes mellitus, chronic kidney disease, and macular degeneration, was admitted to the facility earlier in the year. Despite the facility's policy requiring informed consent for antipsychotic medications, the resident received Nuplazid from April 20th to April 25th without a signed consent form. The responsible party was contacted on April 25th and verbally reviewed the medication's potential side effects but had not signed the consent form by the time of the survey. Interviews with facility staff, including an LVN and the DON, revealed that the signing of consent forms does not always happen immediately. The DON acknowledged the delay between the doctor's order and the responsible party's signing of the consent. The facility's policy clearly states that residents and their representatives must be informed of the risks, benefits, and purpose of antipsychotic medications, and they have the right to refuse such treatments. This lapse in procedure placed the resident and potentially other residents at risk of receiving treatments without proper informed consent.
Failure to Investigate Mechanical Lift Incident
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not conduct an investigation after a mechanical lift incident involving a resident. The incident occurred when the straps of the Hoyer lift tore during a transfer, leaving the resident dangling above the bed and at risk of injury. Despite the resident's fear and the potential for harm, the incident was not reported or investigated as neglect by the staff involved or the administration. The resident involved was a [AGE]-year-old female with multiple medical conditions, including a benign neoplasm of the brain, diabetes, hyperaldosteronism, morbid obesity, major depressive disorder, anxiety disorder, drug-induced polyneuropathy, and lymphedema. She required maximal assistance for various activities of daily living and was dependent on assistance for all transfers by two persons. During the incident, the resident was being transferred from her bed to a shower chair when the straps of the Hoyer lift tore, causing her to dangle above the bed. The CNAs involved managed to lower her back onto the bed without injury, but the incident was not reported or investigated. Interviews with various staff members, including the Administrator, DON, ADON, and CNAs, revealed inconsistencies in their accounts of the incident and a lack of proper reporting and investigation. The facility's policy on abuse, neglect, exploitation, or misappropriation was not followed, as the incident was not thoroughly investigated. The failure to investigate the incident placed the resident and potentially other residents at risk for similar incidents in the future.
Failure to Timely Report Alleged Neglect and Injuries
Penalty
Summary
The facility failed to ensure that all alleged violations involving neglect were reported immediately to the State Survey Agency within the required timeframe. Specifically, the facility did not report an unwitnessed fall of a resident on 09/03/23, which resulted in a laceration to the right eyebrow and an acute fifth metacarpal neck fracture. Additionally, the facility did not report an incident on 09/28/23 where the same resident was observed with redness to the right forehead and right eyelid without any explanation of how the redness occurred. Furthermore, the facility delayed reporting an injury of unknown origin that occurred on 01/10/2024, only submitting the report on 01/16/2024, well beyond the 24-hour requirement. The resident involved, a female with severe cognitive impairment, was admitted to the facility on 01/11/24 and had multiple diagnoses including dementia with behavioral disturbances, Parkinson's disease, heart disease, type 2 diabetes mellitus, chronic kidney disease, and macular degeneration. The resident was totally dependent on staff for transfers, toileting, and showering. The care plan for the resident indicated that she was at risk for falls due to impaired mobility and incontinence, with specific interventions to anticipate and meet her needs, ensure proper footwear, and follow facility protocol in the event of a fall. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's policy required immediate reporting of allegations involving abuse, neglect, injuries of unknown origin, and other serious incidents. However, the DON and Administrator failed to ensure timely reporting of the incidents involving the resident. The facility's policy on reporting and investigating abuse, neglect, exploitation, or misappropriation of resident property was not followed, as evidenced by the lack of timely reports in the state database (TULIP) for the incidents on 09/03/2023 and 09/28/2023, and the delayed report for the incident on 01/10/2024.
Failure to Investigate Incident with Mechanical Lift
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident during a transfer using a mechanical lift. The resident, who had multiple medical conditions including a benign brain tumor, diabetes, and morbid obesity, experienced a frightening incident where the loops on the straps of the Hoyer lift sling tore, leaving her dangling above her bed. Despite the resident's fear and the potential for serious injury, the incident was not reported or investigated as required by the facility's policy on abuse, neglect, and exploitation reporting and investigating. The CNAs involved did not report the incident immediately, and the torn sling was discarded without further examination or documentation. Interviews with various staff members, including the Administrator, DON, ADON, and CNAs, revealed inconsistencies in the understanding and reporting of the incident. The DON and Administrator did not consider the incident as neglect because no injuries occurred, and it was witnessed by staff. However, the facility's policy mandates that all allegations of abuse and neglect be thoroughly investigated, which was not done in this case. The lack of a thorough investigation and proper documentation of the incident placed the resident and potentially other residents at risk. The facility's failure to investigate the incident properly was evident from the lack of an incident report and the disposal of the torn sling without assessment. The resident expressed her fear and concern about the incident, but her concerns were not adequately addressed. The facility's policy on investigating allegations was not followed, leading to a deficiency in ensuring the safety and well-being of the residents.
Latest citations in Texas
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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