Brightpointe At Lytle Lake
Inspection history, citations, penalties and survey trends for this long-term care facility in Abilene, Texas.
- Location
- 1201 Clarks Dr, Abilene, Texas 79602
- CMS Provider Number
- 676416
- Inspections on file
- 39
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 10 (2 serious)
Citation history
Health deficiencies cited at Brightpointe At Lytle Lake during CMS and state inspections, most recent first.
Dishwasher Water Temperature Below Required Sanitizing Level: The facility failed to ensure the low-temperature dishwasher reached the required 120-degree wash temperature. During kitchen observation, the machine was running at 100 degrees on one thermometer and 90 degrees on another, and staff reported the temperature had been below 120 degrees since the new hot water heater was installed. The dishwasher log showed repeated substandard readings, and the Dietary Manager and Maintenance Director both stated the issue had not been reported to them.
Incomplete care plans for wound care, discharge planning, and PICC maintenance: The facility failed to include a resident’s neck wound care in the care plan, failed to include a discharge plan for another resident whose goal was to remain in the facility, and failed to care plan a third resident’s double lumen PICC line maintenance and dressing changes. Records showed the residents had relevant diagnoses and orders for wound treatment and IV antibiotic therapy, while staff interviews confirmed missing PICC maintenance orders and that the care plan only addressed IV antibiotic use.
A resident room on the secured unit had an AC unit cover off and sitting on the floor, exposing the inside of the machine to the resident. An LVN said the cover likely was not put back on correctly after spring cleaning, and the Maintenance Director confirmed the facility had washed the AC units during a facility-wide cleaning. The DON and Administrator were unaware the cover was off.
A resident with a PICC line for IV antibiotics had no physician orders for PICC maintenance, saline flushes, or dressing changes, and the care plan did not include goals or interventions for PICC use and maintenance. Staff stated they were flushing the line and changing the dressing, but these tasks were not ordered on the MAR or TAR, and the DON acknowledged the PICC care had not been care planned.
A resident with hypertension and mobility issues, who was cognitively intact, reported that a CNA entered the room after a call light was activated, yelled at the resident to stop using the call light, and said nurses did not like helping due to frequent use. The resident stated she reported this to the social worker but never received follow-up, while the CNA continued working on her hall. The grievance tracking log reflected the concern, but the grievance binder lacked the corresponding documentation. The Administrator and DON reported they had not received any grievance about the CNA or this incident, whereas the social worker stated she had completed a grievance form and routed it to nursing but did not know its whereabouts. Required steps such as IDT review, development of a resolution plan, notification of the complainant, and full documentation of actions taken were not completed or recorded.
A resident with severe cognitive impairment and on anticoagulant therapy suffered an unwitnessed fall resulting in a head injury. Staff failed to communicate the injury to nursing, did not initiate required neuro checks, and did not document or report changes in the resident's condition. The resident's condition worsened over several days, leading to hospitalization for a subdural hematoma and subsequent death. Facility policies for post-fall assessment and monitoring were not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
The facility failed to adhere to professional standards for food service safety, with several food items found unsealed and open to air in the kitchen's refrigerator and freezers. The DM acknowledged the issue, and the ADMN admitted to being unaware of the exposed food, recognizing the shared responsibility to ensure food safety. The facility's policies and FDA guidelines emphasize the importance of proper food storage and handling to prevent contamination.
The facility failed to inform residents of smoking policies, affecting their self-determination and choice. A resident with moderate cognitive impairment had her cigarettes confiscated and smoking times restricted without prior notice. Another resident, with no cognitive impairment, was not informed of the smoking policy and smoked freely. A third resident was not allowed to sit on the patio due to others not following the smoking policy, and she was unaware of her rights or the grievance process.
The facility failed to ensure that three residents reviewed and signed their admission paperwork, leading to a deficiency in implementing an admission policy. The Admissions/Marketer did not ensure the paperwork was signed, and the Administrator acknowledged this as a system failure. The lack of a formal admissions policy contributed to the issue.
The facility failed to enforce its smoking policy and provide adequate supervision for three residents, leading to unsupervised smoking and potential hazards. A resident with moderate cognitive impairment was found smoking unsupervised with her own cigarettes and lighter, while another resident with no cognitive impairment smoked outside designated times without a smoking assessment or agreement. A third resident with severe cognitive impairment smoked unsupervised, using discarded cigarette butts, despite requiring supervision. Staff interviews revealed inconsistencies in policy enforcement.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in fall prevention and care. A resident with Alzheimer's disease experienced falls without updated interventions, while another with severe cognitive impairment had a care plan lacking specific fall prevention measures. A third resident's care plan was not updated after a fall due to dizziness, and a fourth resident's care plan did not document necessary interventions after multiple falls. These failures placed residents at risk of inadequate care.
A resident's legal representative was not provided with medical records within the required timeframe. Despite requesting the records, the facility delayed the release due to a process involving corporate approval, contrary to their policy of providing records within two working days. The representative was initially misinformed about the need for paperwork and was later told it could take weeks to receive the records.
A resident with severe cognitive impairment and multiple health issues did not receive necessary podiatry services despite having thickened and long toenails. The facility failed to document any podiatry visits or recommendations in the resident's EHR, and staff were unable to provide foot care due to the resident's resistance. This lack of care could have placed the resident at risk of pain and injury.
The facility failed to ensure that a resident or their representative was fully informed and provided consents for antianxiety and antipsychotic medications. The resident, with severe cognitive impairments and multiple diagnoses, did not have signed consents for several medications. Staff interviews confirmed that consents were not properly obtained or documented, and alternative methods to obtain consents were not utilized.
The facility failed to implement policies and procedures to prevent abuse, neglect, and exploitation of residents by not conducting required criminal history and EMR/NAR checks for employees. This deficiency was identified for one employee, placing residents at risk.
A facility failed to report a resident's positive cannabis drug screen to the State Survey Agency in a timely manner. The resident had severe cognitive impairments and multiple diagnoses. The administrator and DON delayed reporting, awaiting further information and guidance from the corporate office, despite state regulations requiring immediate reporting of such incidents.
The facility failed to investigate allegations of abuse and neglect for a resident who tested positive for cannabinoids. Despite being notified of the positive drug screen, the administration did not initiate an investigation, citing a lack of evidence and waiting for additional information. Interviews revealed that the administration and DON were aware of the positive drug screen but did not take immediate action, contrary to the facility's policies.
Dishwasher Water Temperature Below Required Sanitizing Level
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety because the low-temperature dishwasher did not reach the required hot water minimum temperature of 120 degrees. During an initial kitchen observation, the dishwasher was in use and the hot water temperature was observed at 100 degrees on the bottom thermometer and 90 degrees on the top thermometer. The dietary staff member using the machine stated the hot water only reached 100 degrees since the new hot water heater was installed and that she recorded the temperature using only the bottom thermometer. A review of the dishwasher testing log showed repeated temperatures below 120 degrees throughout April 2026, including readings of 90, 95, 98, 100, 105, 110, and 110 degrees across morning, noon, and night checks. The Dietary Manager stated the hot water temperature had been below 120 degrees since the new hot water heater was installed and that she had not told anyone about it. The Maintenance Director stated no one had reported the dishwasher water temperature issue to him and that the new hot water heater had been set to 130 degrees. Later observation showed the dish machine testing at 140 degrees, and the Administrator stated it was now testing at 140 degrees. The facility policy on sanitization stated that low-temperature dishwasher wash temperature should be 120 degrees.
Incomplete care plans for wound care, discharge planning, and PICC maintenance
Penalty
Summary
The facility failed to ensure that the comprehensive care plan addressed Resident #1’s wound on the right side of the neck. Resident #1 was an [AGE]-year-old male admitted with diagnoses including other fracture of the upper and lower end of the right fibula, shortness of breath, morbid obesity, and hypertension. His quarterly MDS dated 01/28/2026 showed a BIMS score of 15, indicating he was cognitively intact. The care plan dated 01/28/2026 contained no evidence of wound care for the neck wound, even though physician orders dated 04/08/2026 directed daily wound care to the right side of the neck with cleansing, xeroform gauze, self-adhesive dressing, and lidocaine gel for daily dressing changes. During observation on 04/07/2026, the resident was in bed with a dressing to the right side of the neck dated 04/07/2026. The facility also failed to include a discharge plan in Resident #58’s care plan. Resident #58 was an [AGE]-year-old female admitted with diagnoses of Type 2 diabetes mellitus, bipolar disorder, hypertension, and chronic pain. Her admission MDS dated 03/13/2026 showed a BIMS score of 12 and indicated participation in assessment and goal setting, with the resident’s overall goal to remain in the facility. The care plan dated 03/24/2026 had no evidence of a discharge plan. Physician orders dated 04/01/2026 included a regular diet, mechanical soft texture, regular consistency, quetiapine, trazadone, duloxetine, antiplatelet monitoring, and full code status. The facility further failed to care plan Resident #97’s double lumen PICC line maintenance and dressing changes. Resident #97 was an [AGE]-year-old male admitted with infection and inflammatory reaction due to an unspecified internal joint prosthesis, anxiety, atrial fibrillation, and dementia. His admission MDS dated 03/17/2026 showed a BIMS score of 3, with IV medications and IV access indicated. The care plan dated 03/17/2026 had no goals or interventions for PICC line use, maintenance, or dressing changes. Physician orders dated 04/01/2026 included IV Tyzavan every 18 hours for MRSA, but there were no orders for PICC maintenance or dressing changes. On observation, the resident had IV antibiotic infusing through a double lumen PICC in the right upper arm, with the dressing clean, dry, and intact. Staff interviews confirmed there was no physician order for PICC flushes or dressing changes, that the resident’s PICC dressing was changed every 7 days, and that the care plan addressed only the PICC line being used for antibiotic therapy.
Exposed Air Conditioning Unit Cover in Resident Room
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when the cover of an air conditioning unit in a resident room on the secured unit was found off the unit and sitting on the floor, exposing the inside of the machine to the resident occupying the room. The observation was made during a room check, and the exposed unit was documented as being in 1 of 14 resident rooms reviewed for accident hazards. During interview, an LVN stated the facility had spring cleaning a few weeks earlier and the cover must not have been put back on correctly after the air conditioning units were washed. The Maintenance Director said the facility had a spring cleaning on 3/18/26 that included washing the air conditioning units and that the cover must not have been put back on correctly. The DON and Administrator were both unaware that any air conditioner covers were off at the time of the observation.
Missing Orders and Care Plan for PICC Line Maintenance
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan, and the resident’s goals and preferences for one resident with a PICC line. The resident was admitted with diagnoses including infection and inflammatory reaction due to an unspecified internal joint prosthesis, anxiety, atrial fibrillation, and dementia, and the admission MDS indicated severely impaired cognition, IV medications, and IV access. The care plan contained no goals or interventions for use and maintenance of the PICC line or for PICC dressing changes, and the physician orders included IV Tyzavan for MRSA but did not include orders for PICC line maintenance, flushes, or dressing changes. During observation, the resident was receiving IV antibiotic therapy through a double lumen PICC line in the right upper arm, and the dressing was clean, dry, and intact. Staff interviews confirmed that IV medications were being given through the PICC line and that the line was being flushed before and after use and the dressing changed every 7 days, but there were no physician orders for these maintenance tasks and they were not on the TAR or MAR. The DON stated there should be physician orders for PICC maintenance, saline flushes, and dressing changes, and acknowledged that the resident’s PICC care had not been care planned.
Failure to Investigate and Document Resident Grievance About CNA Conduct
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and fully investigate a resident’s complaint about staff behavior. A cognitively intact resident with hypertension, reduced mobility, and lack of coordination reported that on one occasion, after using the call light for assistance, a CNA entered the room, yelled at her to stop using the call light, and stated that nurses did not like helping her because she used it too much. The resident stated she reported this incident and her concerns to the social worker and never heard anything further, noting that the CNA continued to work on her hall. Review of the facility’s grievance tracking log showed an entry dated for the resident’s concern involving the CNA, but the grievance binder contained no corresponding grievance documentation for this incident. During interviews, the Administrator stated that no resident or employee had brought concerns about this CNA to him and that he had not received any grievance from this resident. The DON similarly reported that no grievance regarding this CNA or an incident involving this resident had come to her and that she had never received anything about the incident. In contrast, the social worker stated she did complete a grievance form for the resident regarding the CNA yelling at the resident and discouraging call light use, and that, because it was a nursing concern, it should have gone to the DON. She acknowledged she did not know where the grievance document was, and that while the tracking log reflected the incident, the actual grievance form was missing from the binder. The facility’s policy stated that staff are encouraged to guide residents on where and how to file a grievance when they believe their rights have been violated, but the documented process steps described by leadership—review in morning meeting with the IDT, assignment to the appropriate department head, coordination of a resolution plan, and written documentation of actions and disposition—were not carried out or documented for this resident’s grievance.
Failure to Monitor and Communicate After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to protect a resident from neglect following an unwitnessed fall that resulted in a head injury. The resident, who had severe cognitive impairment and was on the anticoagulant Eliquis, was identified as having a cut on the right side of his head after the fall. Despite the presence of a head injury and the resident's high risk for bleeding due to anticoagulant therapy, staff did not communicate the injury to the nurse in a timely manner, nor did they initiate neurological assessments as required by facility policy. Multiple staff members observed the injury and noted changes in the resident's behavior, such as increased lethargy, but did not report these findings or escalate care appropriately. The nurse who eventually assessed the resident performed only a single neurological check and, despite being aware of the resident's anticoagulant use, did not initiate ongoing neuro checks or communicate the incident to other staff or the physician as required. The incident report was completed as a late entry, and there was no documentation of physician notification or of the resident's change in condition. Facility policies required neuro checks for 72 hours after any unwitnessed fall or head injury, especially for residents on anticoagulants, but these protocols were not followed. The resident's condition deteriorated over the following days, with staff and family members observing increased lethargy and a lack of normal behavior. The resident was eventually found unresponsive with blood around the mouth and was sent to the hospital, where a large subdural hematoma was diagnosed. The resident subsequently passed away due to a nonsurvivable head bleed. Interviews with staff and review of records confirmed that required assessments, monitoring, and communication were not performed according to policy, resulting in neglect.
Removal Plan
- The facility RN B was suspended immediately pending investigation by the administrator.
- All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures by the Director of Nursing. For those who cannot be reached by phone will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- The director of nursing was educated on the neurological policy by the VP of Clinical Services. The Director of Nurses was educated by the VP of Clinical Operations, related to the policy stating that neuro checks will be initiated upon any unwitnessed fall or fall with head injury, to continue unless otherwise indicated.
- All current nursing staff were in-serviced on documentation of Unwitnessed falls and Neuro Check Policy by the Director of Nursing. For those who cannot be reached by phone, will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- RN B will complete all in-services 1:1 with the DON if allowed to return work with residents.
- The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect is completed by all staff members. Completion will be reviewed at monthly QAPI meetings.
- DON is responsible for ensuring that all assigned nursing in-service are completed. For those who cannot be reached by phone, will not return to work without receiving this in-service prior to anyone working. The administrator will review any new staff to ensure in-services are completed, prior to their first shift on the floor.
- DON reviewed all other residents on anticoagulants for falls and neuro check documentation. No further injuries were noted on any residents.
- Social worker completed Safe Surveys on the other interviewable residents to ensure they feel safe and free from abuse and neglect. No residents reported signs of Abuse or Neglect.
- Any staff member suspected of committing abuse/neglect will be suspended immediately and/or terminated depending on the outcome of the investigation.
- Staff who fail to report suspected abuse and change in condition will be educated on the significance of reporting time and disciplined accordingly.
- DON/Designee will conduct random questioning on 3 staff members daily for 4 weeks for staff to ensure they are understanding and retaining the education on abuse and neglect and reporting procedures.
- Results from random staff questioning will be reviewed during the monthly QAPI meetings with DON, Administrator, and Medical Director. Any incorrect answers will be corrected immediately. Progress will also be monitored during weekly Committee Meetings and Medical Director will be notified of all progress.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Improper Food Storage and Handling in Facility Kitchen
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the facility's kitchen, it was noted that several food items in Refrigerator #1 and Freezers #1, #2, and #4 were unsealed and open to air. Specifically, a bag of shredded cheese, a box of hamburger patties, a box of egg omelets, a box of mixed vegetables, and a sheet tray of red velvet chocolate chip cookies were found unsealed. Additionally, an opened box of egg rolls and uncovered trays of rolls were observed in Freezer #4. The Dietary Manager (DM) acknowledged that these items were not properly sealed and understood the importance of covering and sealing food to prevent contamination. The Administrator (ADMN) admitted to being unaware of the exposed food in the kitchen and acknowledged the shared responsibility with the DM to ensure food safety. The ADMN stated that the kitchen staff should have adhered to the facility's food storage policies to prevent residents from consuming contaminated food, which could lead to illness. The facility's Food Safety and Sanitation Plan emphasized the need for food to be stored off the floor and covered, and the FDA Food Code 2022 highlighted the importance of proper date marking and disposition of food items.
Failure to Inform Residents of Smoking Policies
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice, specifically regarding the right to make choices about smoking. Three residents were affected by this deficiency. Resident #97, a female with moderate cognitive impairment, was not informed of the smoking policies, resulting in her cigarettes being confiscated and restrictions placed on her smoking times. Despite having a care plan that acknowledged her nicotine addiction and the need for supervised smoking, there was no evidence that staff discussed the smoking policy with her upon admission or during her stay. Resident #78, a male with no cognitive impairment, also was not informed of the smoking policies upon admission. His comprehensive care plan did not address smoking or resident rights, and there was no evidence of a smoking assessment in his records. He was allowed to smoke whenever he wanted, as staff provided him with cigarettes upon request, indicating a lack of adherence to the facility's smoking schedule. Resident #304, a female with no cognitive impairment, was not allowed to sit on the patio due to other residents not following the smoking policy, despite it not being a designated smoking time. She was not informed of her rights or the grievance process, which made her feel that her rights were not important. The facility's policy required that all residents and family members be notified of the smoking policy during the admission process, but this was not done, leading to confusion and non-compliance with the smoking policy among residents.
Failure to Implement Admission Policy and Secure Signed Agreements
Penalty
Summary
The facility failed to implement an admission policy for three residents, resulting in the absence of signed admission agreements. Resident #97, a female with moderate cognitive impairment, was admitted without reviewing or signing her admission paperwork. Similarly, Resident #78, a male with no cognitive impairment, and Resident #304, a female also with no cognitive impairment, were admitted without signing their admission agreements. Interviews with these residents confirmed that they did not go over or sign any admission paperwork, and Resident #304 was not informed about resident rights or grievance procedures. The Admissions/Marketer admitted to not ensuring the admission paperwork was signed, citing a lack of awareness of the policy and not perceiving any negative outcomes from this oversight. The Administrator acknowledged the issue as a system failure, noting that the lack of a signed admission agreement could lead to residents being unaware of their rights and the facility's expectations. The facility did not have a formal admissions policy in place, and the document titled 'Admission Agreement' was not dated, further contributing to the deficiency.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to the smoking policy for three residents, leading to potential accident hazards. Resident #97, a female with moderate cognitive impairment, was observed smoking unsupervised with her own cigarettes and lighter, contrary to her care plan which required supervision and storage of smoking materials by staff. There was no evidence of a signed smoking agreement or documentation that staff had discussed the smoking policy with her. Resident #78, a male with no cognitive impairment, also smoked unsupervised and outside designated times. His care plan did not address smoking, and there was no smoking assessment or signed agreement in his records. He reported that staff provided him with cigarettes outside of scheduled smoking times, indicating a lack of adherence to the facility's smoking policy. Resident #74, a male with severe cognitive impairment, was observed smoking unsupervised and using discarded cigarette butts. Despite his care plan indicating he could smoke independently, his smoking assessment required supervision. There was no signed smoking agreement, and staff interviews revealed inconsistencies in enforcing the smoking policy, with residents having access to cigarettes and lighters against facility rules.
Deficiencies in Care Plan Implementation and Fall Prevention
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which resulted in deficiencies in addressing their individual needs and fall prevention. Resident #1, an elderly female with Alzheimer's disease and a history of falls, had care plan interventions that were not updated since October 2023, despite recent falls. Observations revealed that staff were not present in the hallway when Resident #1 fell, and interviews indicated that staff were unaware of recent falls, highlighting a lack of communication and implementation of care plan interventions. Resident #2, who has severe cognitive impairment and a history of falls, had a care plan that did not include specific interventions to prevent falls, such as stopping staff from guiding her with touch, which was identified as a trigger for her anxiety and falls. Despite having fallen and sustained injuries, the care plan was not updated to reflect necessary interventions, and the resident's representative was not informed of care plan meetings or fall prevention strategies. Resident #3, with Alzheimer's disease and a history of falls, had a care plan that lacked updates and specific interventions for fall prevention, such as frequent toileting and physical guidance. The resident fell due to dizziness, and the care plan did not reflect changes in interventions post-fall. Similarly, Resident #4, with dementia and a history of falls, had a care plan that was not updated after multiple falls, and interventions such as placing a mattress on the floor were not documented. The facility's failure to update and implement care plans placed residents at risk of not receiving adequate care to meet their needs.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident's legal representative with access to medical records within the required timeframe. The representative of a resident, who had severe cognitive impairment and was diagnosed with dementia, requested the resident's medical records on 10/29/2024. Despite the facility's admission agreement stating that records should be provided within two working days, the records were not released in this timeframe. Interviews revealed that the facility's process for releasing medical records involved sending requests to a corporate office, which delayed the release. The Administrator and Medical Records staff were under the impression that they had up to 14 or 15 days to release the records, contrary to the facility's policy. The representative was initially told no paperwork was needed, but later had to fill out a form, and was informed it could take 2-3 weeks to receive the records. The facility's policy required corporate approval before releasing records, which contributed to the delay. The representative did not receive any communication about payment or denial of the request, and the facility did not provide the records within the stipulated two working days. This failure to comply with the policy could potentially place residents and their representatives at risk by not having timely access to important health information.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure that a resident received proper foot care and treatment in accordance with professional standards of practice. Resident #4, who had severe cognitive impairment and multiple health issues including dementia, muscle weakness, and a history of falls, did not receive podiatry services despite having thickened and long toenails. The resident's responsible party (RP) had requested podiatry services, but there was no documentation of any appointments or recommendations for podiatry care in the resident's electronic health record (EHR). The facility's records showed that Resident #4's toenails were documented as long on multiple occasions, yet no action was taken to address this issue. Nursing assistants (NAs) noted that the resident's toenails were complicated, and they were not able to perform foot care. The social worker (SW) was responsible for coordinating podiatry visits but failed to document any visits or refusals in the EHR. Interviews with staff revealed that attempts to provide foot care were met with resistance from the resident, who would pull away and become agitated. Despite the facility's policy requiring referrals to a podiatrist for residents with complicating disease processes, there was no evidence that Resident #4 was seen by a podiatrist. The Director of Nursing (DON) and other staff members were unable to provide any documentation of podiatry visits or notes for Resident #4. This lack of proper foot care could have placed the resident at risk of pain, injury, and decreased quality of life.
Failure to Obtain Medication Consents
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consents for the administration of certain medications. Specifically, Resident #1 did not have signed consents for antianxiety and antipsychotic medications, including Clonazepam, Ativan, Divalproex, Temazepam, Risperidone, Aripiprazole, and Haloperidol. This failure was identified through record reviews and interviews with staff and the resident's representative, revealing that the necessary consents were either missing or incomplete. Resident #1, a [AGE] year-old female with diagnoses including Cerebral Palsy, Bipolar disorder with psychotic features, Depression, Anxiety, and Autistic Disorder, had severe cognitive impairments and required substantial assistance with daily activities. Despite these conditions, there was no evidence of signed consents for the medications prescribed to her. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Medical Records (MR) staff, and the Medical Director (MD) confirmed that the consents were not properly obtained or documented. The DON admitted that the facility did not use alternative methods to obtain the necessary consents, such as email or phone communication, and relied on in-person visits from the resident's representative, who lived in a different town. The ADON acknowledged being behind on consents due to illness, and the MD stated that consents were not signed because the resident was hospitalized. The resident's representative confirmed that she had not been contacted for consents beyond the initial admission paperwork. This lack of proper consent documentation could lead to the resident's representative being unaware of the medications and their potential side effects, as well as the associated risks and benefits.
Failure to Implement Policies to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not conduct criminal history checks and/or EMR/NAR checks prior to offering employment and annually for employees. This deficiency was identified for one of eight employees reviewed for employability, placing residents at risk of receiving care from someone who might be unemployable. The personnel file of CNA-A, who was hired on 08/02/2022, lacked documented evidence of a criminal history check and initial or annual EMR/NAR checks. Interviews with facility staff revealed inconsistencies and lapses in the hiring process. The current HR, hired in 02/2024, acknowledged the absence of necessary documents in CNA-A's file. The previous HR, who served until 02/2024, admitted that criminal history and EMR/NAR verifications were not consistently conducted. The Administrator and DON also confirmed the lack of a process to ensure these checks were completed, attributing the responsibility to HR. The failure to conduct proper background checks potentially exposed residents to staff with abusive or neglectful backgrounds.
Failure to Report Positive Drug Screen
Penalty
Summary
The facility failed to report allegations of abuse and neglect involving a resident who tested positive for cannabis in a timely manner. The resident, a female with severe cognitive impairments and multiple diagnoses including Cerebral Palsy, Bipolar disorder, Depression, Anxiety, and Autistic Disorder, had a positive hospital lab result for cannabis. The facility's administrator, who was also the abuse coordinator, was informed of the positive drug screen but did not report it to the State Survey Agency as required by regulations. Instead, the administrator waited for further information and confirmation from the corporate office and hospital records before deciding whether to report the incident. During interviews, the administrator and the Director of Nursing (DON) both indicated that they were uncertain about the necessity of reporting the positive drug screen. They relied on guidance from the corporate office and the presence of a surveyor in the facility to delay the reporting process. The DON acknowledged that if the lab result was accurate, other residents could have been at risk, but she did not believe there was a failure in not reporting the incident to the Health and Human Services Commission (HHSC). The facility's policy and state regulations require immediate reporting of any suspected abuse, neglect, or exploitation, including incidents resulting in serious accidental injury or hospitalization. Despite this, the facility did not report the positive drug screen to the appropriate authorities within the required timeframe. This failure to report could potentially place residents at risk by delaying the investigation and intervention by the facility and state agencies.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for a resident who tested positive for cannabinoids (marijuana). The resident, a female with severe cognitive impairments and multiple diagnoses including Cerebral Palsy, Bipolar disorder with psychotic features, Depression, Anxiety, and Autistic Disorder, had a positive urine drug screen result from the hospital. Despite being notified of the positive drug screen, the facility's administration did not initiate an investigation, citing a lack of evidence and waiting for additional information from the hospital. The facility's incident report files showed no evidence of an investigation into the allegations of abuse or neglect for this resident. Interviews with the facility's administration and Director of Nursing (DON) revealed that they were aware of the positive drug screen but did not take immediate action to investigate. The Administrator stated that he did not feel there was a failure in not investigating and was waiting for all the evidence before proceeding. The DON confirmed that they were waiting for the resident's hospital records and acknowledged that failing to begin an investigation could place other residents at risk. The facility's policies on resident abuse/neglect reporting and conducting internal investigations were not followed, as they require immediate investigation upon receiving an allegation of abuse or neglect.
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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