Mitchell County Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Colorado City, Texas.
- Location
- 971 W I 20, Colorado City, Texas 79512
- CMS Provider Number
- 676225
- Inspections on file
- 25
- Latest survey
- April 28, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Mitchell County Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to protect resident dignity and privacy when CNAs used personal cell phones while providing care, including showers and feeding. Seven residents said the behavior happened on every shift, made them feel ignored and embarrassed, and caused privacy concerns and delays between bites during meals. The DON and ADM stated staff should focus fully on residents and that cell phones were not allowed in resident care areas.
Failure to Invite Residents and Representatives to Care Plan Meetings The facility did not document advance notice or invitations for care plan/IDT meetings for multiple residents, including residents with dementia, cognitive impairment, mobility limitations, pain needs, wounds, therapy services, and complex medical diagnoses. Interviews showed residents and family members were not invited to meetings, and staff stated the IDT discussed care plans internally while the DON called families with updates instead of holding or documenting formal care plan conferences.
Grievance Procedure Not Made Available to Residents: The facility failed to provide 9 of 10 residents with accessible information on how to file a grievance or complaint. Residents stated they did not know about anonymous grievances, where to get a grievance form, who to submit it to, what happens after filing, or that they could receive a written decision. Observations showed the posted information did not include grievance instructions, while the ADM stated she was the grievance officer and that forms were available in the entryway hallway and at the nurses' station.
A kitchen survey found food items in the refrigerator and freezer stored in clear bags with no use-by dates, and a garbage can next to the prep table left uncovered while not in use. Staff and leadership stated that kitchen staff were responsible for dating and labeling food, the DM was responsible for monitoring it, and that the uncovered trash can should have had a lid. Facility policy required refrigerated and frozen foods to be covered, labeled, and dated, and refuse containers to be covered when not in use.
A resident meal service deficiency occurred when multiple residents reported cold, bland, and poorly textured food, and surveyors found that most sampled tray items were cold, with some mushy, sticky, or chunky. Kitchen and admin staff said they were responsible for monitoring food temp, texture, and flavor, but could not explain the poor quality; they also reported a malfunctioning steamtable and possible delays in serving. The facility policy required palatable, visually appealing meals served at appropriate temperatures.
Incomplete DNR Form: A resident with dementia, AKF, and DM2 had a DNR order documented on the face sheet, physician order summary, and care plan, but the OOH DNR form was incomplete because the physician did not print his name and the license number was missing. The BOM and ADM both confirmed the form was not valid if not filled out correctly and stated there was no system to monitor DNR accuracy.
Two residents received PRN Lorazepam orders without the required 14-day stop date, and the record did not show a documented diagnosed specific condition supporting PRN psychotropic use. One resident had dementia, moderate cognitive impairment, and hospice care with Lorazepam administered on multiple occasions, while the other had dementia with severe cognitive impairment and hospice care with a long-standing PRN Lorazepam order for anxiety and restlessness. The DON and ADM acknowledged PRN psychotropics required review for stop dates, and the facility policy stated PRN psychotropic use must be tied to a documented specific diagnosis and limited to 14 days.
Failure to Follow Standard Precautions During Perineal Care: Two CNAs were observed performing peri-care without proper hand hygiene and glove changes. One CNA cleaned a resident with dementia and incontinence, then placed a clean brief without changing gloves or cleaning hands. Another CNA removed gloves after peri-care, put on a new pair without hand hygiene, and then assisted a resident with standing and dressing. The ADON, who also served as the IP, acknowledged the issue and the facility policy required hand hygiene after glove removal and before moving from a contaminated to a clean body site.
The facility failed to maintain RN coverage for at least eight consecutive hours per day, seven days a week, on four specific days. Staff interviews revealed a lack of awareness and understanding of the RN coverage policy. The DON and ADON were responsible for ensuring coverage but were unaware of the uncovered days until later. The absence of RN coverage could potentially place residents at risk of inadequate care.
The facility was found to have deficiencies in food storage and hygiene practices, including expired and dented canned foods, improper hand hygiene by kitchen staff, and unlabeled food items. A dishwasher was observed wrapping silverware without washing hands or wearing gloves, despite being trained to do so. The kitchen manager admitted to not being aware of expired foods, and the dietary manager emphasized the importance of proper hygiene to prevent health risks to residents.
The facility failed to develop comprehensive care plans for six residents, lacking measurable objectives and timeframes for addressing medical, nursing, mental, and psychosocial needs. Care plans were not updated or individualized for issues like vision, communication, and urinary incontinence. Staff interviews revealed a lack of awareness and training in care plan creation and updates.
The facility failed to ensure resident privacy during wound care for two residents, leading to potential exposure. An RN did not fully close privacy curtains or window blinds during care, despite being trained to do so. The facility's administration was unaware of these lapses, although their policy emphasized maintaining resident dignity and privacy.
A resident with severe cognitive impairment received Trazadone for depressive episodes without informed consent, as required by the facility's policy on psychotropic medications. Staff interviews revealed a lack of awareness and a clear system for obtaining medication consents, leading to the administration of the medication without the necessary consent from the resident or their representative.
A facility failed to honor a resident's DNR order due to inconsistent documentation across the EMR, care plan, and physical chart. Despite having a valid DNR, the resident was listed as full code in the EMR, risking unwanted CPR. Staff interviews revealed reliance on incorrect records, and the facility's policy on advance directives was not followed, leading to a violation of the resident's rights.
The facility failed to ensure the medication cart for hall 100 was free of expired medications, as observed with a bottle of Acetaminophen 500 mg/Diphenhydramine HCl 25 mg past its expiration date. RN B confirmed the oversight, and both the DON and ADM were unaware of the expired medication, despite it being the nursing staff's responsibility to remove such items. The facility's policy requires nursing staff to maintain medication storage and contact the pharmacy for expired items.
The facility failed to properly store medications on the Hall 100 medication cart, where two loose pills were found. RN B, responsible for checking the cart, was unaware of how the pills became loose. The DON and ADM were also unaware of the issue, despite facility policies requiring medications to be stored in their original packaging and kept orderly. This lapse in adherence to the policy was observed during a survey.
A long-term care facility failed to maintain an effective infection control program, as evidenced by two incidents involving staff and residents. An RN did not sanitize her hands between glove changes during wound care for a resident with a pressure ulcer, while a CNA did not wear a gown during catheter care for a resident on Enhanced Barrier Precautions. Both staff members acknowledged their lapses, and the facility's policy requires gowns and gloves during high-contact care activities to prevent infection.
The facility failed to provide education and document pneumococcal and influenza immunization status for two residents, both with severely impaired cognition. Staff interviews revealed a lack of awareness and accountability in the immunization process, with the ADON responsible for monitoring. The facility's policy required offering the influenza vaccine annually, but this was not followed, leading to the deficiency.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy when staff used personal cell phones while providing care, including assisting with showers and feeding residents. Seven confidential residents reported that CNAs were on their cell phones during care on every shift, which made them feel ignored, not a priority, embarrassed, and concerned that staff could make mistakes because they were distracted. The residents also stated that their privacy was violated and that they did not know the names of the CNAs involved. The same residents reported that staff also used cell phones while feeding residents during meals, causing significant wait times between bites. During interviews, the DON and ADM stated residents should receive privacy and full staff attention during care, that cell phone use was not allowed in resident care areas, and that staff were trained on resident rights, dignity, privacy, and cell phone use during orientation and in-services. The facility policy titled Resident Rights stated employees shall treat all residents with kindness, respect, and dignity and protect privacy and confidentiality.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents had the right to participate in the development and implementation of their person-centered plans of care for 13 of 13 residents reviewed for comprehensive care plans. Record review and interviews showed that the facility did not document invitations for care plan meetings for Resident #1, Resident #2, Resident #20, or 10 additional confidential residents, and there was no documentation that these residents or their representatives were provided prior notice to participate in care plan meetings. Resident #1 was a female admitted with diagnoses including fracture of the right femur, anemia, pneumonia, hypertension, acute diastolic congestive heart failure, macular corneal dystrophy, history of cerebral infarction, and history of falling. Her admission MDS showed minimal hearing difficulty, impaired vision with corrective lenses, BIMS 11/15, limited to moderate ADL assistance needs, use of a walker and wheelchair, pain requiring PRN medication, a mechanically altered diet, wound care needs, and therapy services. Her care plan addressed triggered concerns from the admission MDS, and her overall goal was discharge to the community, but the record did not show any IDT or care plan meeting documentation between admission and the survey review period. During interview, Resident #1 stated she did not think she had participated in a care plan meeting, and a family member stated the facility communicated with him individually rather than through a care plan/IDT meeting. Resident #2 was a male with diagnoses including dementia, altered mental status, chronic hepatitis C, hyperlipidemia, depressive disorder, PTSD, polyneuropathy, osteoporosis, urethral fistula, and traumatic brain injury. His quarterly MDS showed impaired vision with corrective lenses, BIMS 5/15, wheelchair use, extensive ADL assistance, frequent bladder incontinence, an ostomy for bowel, falls, mechanically altered diet, skin tears and moisture associated skin damage, and use of antidepressant and antibiotic medications. His care plan addressed triggered concerns, but the record did not show any IDT or care plan meeting documentation during the review period. A family member stated he had not been invited to or attended any care plan/IDT meeting regarding Resident #2's care. Resident #20 had diagnoses including dementia, acute kidney failure, acquired absence of specified parts of the digestive tract, cholecystitis, atrial fibrillation, arthritis, type 2 diabetes mellitus, insomnia, depressive disorder, hypertension, and GERD. Her quarterly MDS showed impaired vision with corrective lenses, BIMS 6/15, wheelchair use, extensive ADL assistance, incontinence of bladder and bowel, medically complex conditions, scheduled pain medication, a mechanically altered diet, moisture associated skin damage, insulin injections, and antidepressant use. Her care plan addressed triggered concerns, but there was no documentation of an IDT or care plan meeting during the review period, and her family member stated she had never been invited to a care plan/IDT meeting. Interviews with staff showed the MDS Coordinator stated they did not send letters or have care plan meetings, and that the IDT team met to discuss the plan of care while the DON called families with updates. The DON stated the facility got the IDT team together, reviewed residents' care plans, and then called family members or responsible parties to discuss quarterly and annual assessments, but did not send letters to invite residents or family members to care plan meetings. The DON also stated that during COVID-19 the meetings were done by phone and never started back, and that she documented notifications on paper because the EMR did not have a place for notes. The Administrator stated she had been told the MDS nurse did not do care plan meetings and that the DON notified families with updates, and she acknowledged the importance of notifying residents and families and giving them a chance to talk to the IDT about questions or concerns. The facility policy stated residents have the right to participate in care planning, receive advance notice of care planning conferences, and have an explanation documented if participation is not practicable.
Grievance Procedure Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 9 of 10 confidential residents reviewed. During interviews and record review, those residents stated they did not know they could file a grievance anonymously, that the grievance procedure had never been discussed in Resident Council, and that they had not observed a posting of the grievance procedure in prominent locations. They also stated they did not know where to obtain a grievance form, who to give it to, what happened after a grievance was filed, or that they had the right to receive a written decision once the grievance was resolved. Observations of prominent postings on 04/28/2026 at 3:00 PM showed the facility did not include instructions regarding the grievance procedure with any of the prominent postings. During interview on 04/28/2026 at 3:35 PM, the ADM stated she was the grievance officer, that grievance forms were available on a shelf in the entryway hallway and at the nurses' station, and that the Activities Director completed grievance forms during monthly Resident Council meetings when concerns were voiced. The ADM also stated staff completed grievance forms for some complaints discussed face to face, that grievances were assigned to the appropriate department for resolution, and that completed forms were kept in a notebook for 3 plus years. Record review showed the grievance policy stated a copy of the grievance/complaint procedure should be posted on the resident bulletin board, and the policy last updated in April 2017 stated the ADM assigned grievance investigation to the grievance officer and that the resident or person filing the grievance would be informed of the findings.
Food Storage and Sanitation Lapses in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, a garbage can next to the food prepping table was observed uncovered and not in use. In the walk-in refrigerator, hamburger buns and lettuce were found in separate clear plastic bags with no use-by date. In the walk-in freezer, chicken breast patties, mixed vegetables, and grilled chicken meat burgers were found in separate clear plastic bags with no use-by date. During interviews, kitchen staff and leadership stated that staff were responsible for labeling and dating food items, and that the DM was responsible for monitoring labeling and dating. One staff member stated she may have been rushing and forgot to put the dates and labels on the food items. The same staff member stated the garbage can next to the food prepping table should have been covered at all times unless in use. The RD, ADM, and DM each stated that undated or unlabeled food items and an uncovered garbage can could cause food contamination or food poisoning, and that the garbage can should have had a lid when not in use. Record review of the facility's Food Receiving and Storage policy stated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated with a use-by date, and refrigerated foods are to be monitored so they are used by their use-by date, frozen, or discarded. Record review of the Sanitation policy stated that garbage and refuse containers are to be properly contained with lids or otherwise covered. The observed food storage and sanitation conditions did not match those policy requirements.
Meals Served Cold and Poorly Prepared
Penalty
Summary
The facility failed to provide food and drink that were palatable, attractive, and served at a safe and appetizing temperature. During the initial tour, four residents voiced concerns about the food. One resident said the food was greasy, had no seasoning or taste, and was cold and never hot. Another resident stated the food had no texture, no variety, was not hot, and that the vegetables were overcooked. A third resident said the food was of poor quality and that he ate sandwiches instead, and a fourth resident reported that meals were cold, there was no variety, and the chicken was dry. On observation, a sample tray was requested to include all food forms served, including the alternate plate. When the tray was delivered to the survey room, surveyors found that five of nine sampled foods were cold. One sampled item was mushy, one was sticky, and one pureed item was chunky. The sampled foods included regular, mechanical, and pureed items, and the findings showed problems with temperature, texture, flavor, and appearance across the meal forms served. During interviews, kitchen and administrative staff stated they were responsible for monitoring temperature, texture, and flavor, but could not explain why the meals were not palatable. Staff reported that the middle steamtable was not working properly or had been out of service for about a month, and that meals may not have been served quickly enough after being placed on the serving line. The dietary policy in the record stated that meals should be palatable, visually appealing, and served at appropriate temperatures, with standardized recipes, attractive plating, and texture-modified foods maintaining moisture and flavor.
Incomplete DNR Form
Penalty
Summary
The facility failed to ensure that Resident #20’s right to formulate an advance directive was honored because the resident’s Out-of-Hospital Do Not Resuscitate form was incomplete. Resident #20 was a female admitted to the facility with diagnoses including dementia, acute kidney failure, and type 2 diabetes. Her face sheet listed DNR under advance directives, and the physician order summary and care plan also reflected a DNR order. Record review of the DNR form showed the physician did not print his name after signing, and the physician license number was missing. During interviews, the BOM and ADM both stated the DNR was not valid if it was not filled out correctly and verified the missing information on Resident #20’s form. They stated there was no system for monitoring DNRs for accuracy and identified human error as the reason the form was incomplete.
PRN Lorazepam Orders Lacked Required Limits and Documentation
Penalty
Summary
The facility failed to ensure that two residents did not receive PRN psychotropic medication without a documented diagnosed specific condition in the clinical record and failed to ensure PRN orders for Lorazepam were limited to 14 days. Resident #21 had a history of unspecified dementia without behavioral disturbance, type 1 diabetes with nephropathy, cerebral infarction, and hospice care. Her quarterly MDS showed moderate cognitive impairment with a BIMS score of 8, and the active diagnoses section did not list anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, or PTSD. Her care plan included PRN Lorazepam for restlessness and anxiousness, and physician orders dated 9/19/2025 included Lorazepam Intensol oral concentrate every 4 hours as needed for mild to moderate anxiety or agitation. Resident #21’s MAR showed Lorazepam was administered in March and April 2026, but the order did not have a stop date and extended beyond 14 days. Resident #40 had shortness of breath, delirium due to known physiological conditions, dementia with mood disturbance, and hospice care. Her quarterly MDS showed severe cognitive impairment with a BIMS score of 6, and the active diagnoses section did not list anxiety disorder, depression, bipolar disorder, psychotic disorder, schizophrenia, or PTSD. Her care plan included PRN Lorazepam for psychotropic medication use, and physician orders dated 10/01/2024 included multiple PRN Lorazepam concentrate doses every 2 hours as needed for anxiety and restlessness. Resident #40’s MAR for February, March, and April 2026 did not show any administered Lorazepam doses, but the PRN order also lacked a stop date and remained beyond 14 days. During interviews, the DON stated PRN psychotropic medication should not go past 14 days except, in her belief, for hospice residents, and the ADM stated the DON was responsible for ensuring PRN psychotropics were reviewed for stop dates. The facility policy stated PRN psychotropic medications are not to be prescribed or administered unless necessary to treat a diagnosed specific condition documented in the clinical record, and PRN orders are limited to 14 days.
Failure to Follow Standard Precautions During Perineal Care
Penalty
Summary
The facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection during perineal care for 2 residents. During observation of care for one resident with dementia, severe cognitive impairment, and total incontinence of bladder and bowel, a CNA cleaned the resident’s buttocks after a bowel movement, removed a glove from only one hand, applied a glove to that hand only without hand hygiene, and then placed a clean brief under the resident without changing gloves or performing hand hygiene. During observation of care for another resident admitted with a right femur fracture and moderate cognitive impairment, a CNA performed peri-care while the resident was on the toilet, then removed gloves and put on a new pair without using hand sanitizer or washing hands before assisting the resident to stand and pulling up the brief and pants. The CNA stated she should have used hand sanitizer before putting on the new gloves and said she had been checked off on peri-care about a week earlier. The ADON, who also served as the Infection Preventionist, stated she already knew there was a problem because some CNAs had reported what they had done and she told them it was not right. She described her expectations for peri-care and reviewed the facility’s check-off sheet. The facility policy on Standard Precautions stated that hand hygiene is performed after removing gloves and that gloves are changed and hand hygiene performed before moving from a contaminated body site to a clean body site during resident care.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight consecutive hours per day, seven days a week, on four specific days. This deficiency was identified during a review of nursing services for the period from January 17, 2025, to February 18, 2025. The absence of RN coverage on January 25, 26, and February 8, 9, 2025, was confirmed through interviews and record reviews. The facility's policy requires RN coverage to provide continuous daily care, oversee shifts, and assist licensed vocational nurses (LVNs) with decision-making in critical situations. Interviews with staff revealed a lack of awareness and understanding of the RN coverage policy. RN B and RN C mentioned their roles in providing guidance to LVNs and pronouncing death, but there was no indication of their presence on the uncovered days. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were responsible for ensuring RN coverage, but both were unaware of the uncovered days until the issue was brought to their attention. The ADON admitted to not making additional efforts to cover the shifts when a volunteer RN called in, and the DON was unavailable to cover the shifts herself. The facility's policy mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. However, the system in place to monitor RN coverage relied heavily on the ADON and DON, who failed to ensure compliance with this requirement. The Administrator (ADM) also relied on the DON for monitoring RN coverage and was unaware of the uncovered days until reviewing the time sheets. The lack of RN coverage on the specified days could potentially place residents at risk of not receiving adequate care.
Deficiencies in Food Storage and Hygiene Practices
Penalty
Summary
The facility was found to have several deficiencies in its dietary services, specifically in the storage, preparation, and serving of food. During an inspection, it was observed that the facility had expired and dented canned foods in its storage pantry, including sweetened condensed milk, evaporated milk, and green chili peppers. Additionally, several food items such as Ritz crackers, Fritos chips, and ranch dressing were past their expiration dates. There was also an unlabeled baggie of what appeared to be coffee grounds without a proper date label. These issues indicate a failure to adhere to proper food storage and labeling practices, which are essential to prevent food contamination and foodborne illnesses. The inspection also revealed improper hand hygiene practices by kitchen staff. A dishwasher was observed wrapping silverware without washing her hands or wearing gloves, despite being trained to do so. This occurred on multiple occasions, and the dishwasher acknowledged her failure to follow proper procedures, which could lead to the spread of germs and infections. The kitchen manager confirmed that staff had been trained on handwashing and glove use, but acknowledged the oversight in monitoring and enforcing these practices. Interviews with the kitchen manager, dietary manager, and administrator highlighted a lack of adherence to established policies and procedures regarding food safety and hygiene. The kitchen manager admitted to not being aware of the expired foods and stated that it was his responsibility to ensure expired items were removed. The dietary manager emphasized the importance of disposing of expired foods and maintaining proper hygiene to prevent health risks to residents. The administrator expressed an expectation for staff to follow policies, but noted the absence of a specific policy related to expired canned goods. These deficiencies in food handling and hygiene practices could potentially compromise the health and safety of the residents.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for six residents, which included measurable objectives and timeframes to address their medical, nursing, mental, and psychosocial needs. The care plans were not updated or individualized to address specific issues such as vision, communication, urinary incontinence, and psychosocial well-being. This deficiency was identified through observations, interviews, and record reviews, revealing that the care plans lacked necessary interventions and goals. For Resident #10, the care plan did not include interventions for visual function or communication, despite the resident having severely impaired cognition and requiring specific communication strategies. Similarly, Resident #24's care plan was missing interventions for vision and communication, even though the resident had severe cognitive impairment and specific communication challenges. Resident #27's care plan lacked interventions for visual function and urinary incontinence, despite the resident's moderate cognitive impairment and need for assistance with these issues. Resident #34's care plan did not address visual function, although the resident had impaired vision and required glasses. Resident #36's care plan also lacked interventions for visual function, despite the resident's need for glasses during certain activities. Lastly, Resident #39's care plan was missing interventions for visual function, communication, urinary incontinence, and psychosocial well-being, even though the resident had severe cognitive impairment and multiple related challenges. Interviews with staff revealed a lack of awareness and training regarding the creation and updating of care plans, contributing to the deficiency.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promoted their quality of life. Specifically, the facility did not protect and promote the rights of two residents, Resident #35 and Resident #41, by failing to provide privacy during wound care procedures. This deficiency was observed during wound care sessions where RN C did not fully pull the privacy curtain or close the window blinds, exposing the residents to potential bodily exposure to the hallway and facility exterior. Resident #35, a male with diagnoses including adult failure to thrive, anxiety, dementia, and a stage 2 pressure ulcer, was observed during a wound care session where RN C did not ensure privacy by failing to close the curtain and window blinds. This oversight occurred despite RN C's acknowledgment of the importance of privacy during personal care and her training to provide such privacy. The resident's bed was positioned near the window, and there was a roommate present, increasing the risk of exposure. Similarly, Resident #41, a female with age-related cognitive decline, chronic kidney disease, and a stage 2 pressure ulcer, experienced a similar lack of privacy during wound care. RN C admitted to concentrating on the wound care steps and forgetting to close the curtain and blinds. The facility's administration was unaware of these privacy lapses, although the facility's policy emphasized the importance of maintaining resident dignity and privacy during personal care. The ADM confirmed that the expectation was for staff to always provide privacy by closing doors, curtains, and blinds during care.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment, specifically regarding the administration of the antipsychotic medication Trazadone for depressive episodes. The deficiency was identified for one resident who was receiving psychoactive medications without informed consent, placing them at risk of receiving treatments without their or their representative's informed consent. The resident in question had a severely impaired cognition, as indicated by a BIMS score of 06, and was unable to communicate effectively due to aphasia and other cognitive deficits. The facility's policy requires that psychotropic medications, such as antipsychotics and anti-anxiety medications, be prescribed, monitored, and reviewed with the involvement of residents, families, and/or representatives. However, the facility did not obtain a signed consent for the administration of Trazadone to the resident, despite the medication being administered from February 1 to February 17, 2025. Interviews with facility staff, including the MDS Coordinator, DON, ADM, and ADON, revealed a lack of awareness of any missing medication consents and an absence of a clear system to ensure that consents were obtained before administering psychotropic medications. The facility's policy on psychotropic medication use emphasizes the importance of obtaining consent to ensure that residents and their representatives are informed about the medication, its potential side effects, and the right to decline treatment. Despite this, the staff interviews indicated that the responsibility for obtaining consent was not clearly defined, and there was no consistent monitoring system in place to ensure compliance with the policy. The deficiency highlights a gap in the facility's processes for managing medication consents, particularly for residents with cognitive impairments who are unable to advocate for themselves.
Failure to Honor Resident's DNR Order
Penalty
Summary
The facility failed to ensure that a resident's advance directive and code status were accurately documented and communicated across all relevant platforms. Resident #27, who was admitted with diagnoses including Parkinson's disease and moderate cognitive impairment, had a completed Do Not Resuscitate (DNR) order that was not reflected in the electronic medical record (EMR). Despite having a valid DNR order, the resident's EMR incorrectly listed him as full code, indicating that CPR should be performed in the event of cardiac arrest. Interviews with various staff members, including Licensed Vocational Nurses (LVNs), Registered Nurses (RNs), the Minimum Data Set (MDS) Coordinator, and the Director of Nursing (DON), revealed inconsistencies in the facility's documentation and communication of code status. Staff members relied on the EMR and a list at the nurse's station to determine a resident's code status, but the list was not observed at the nurse's station, and the EMR for Resident #27 was incorrect. The DON and Assistant Director of Nursing (ADON) acknowledged the importance of consistent and accurate information but were unaware of the discrepancies in Resident #27's records. The facility's policy on advance directives requires that such documents be maintained in a readily accessible location and that the resident's wishes be communicated to direct care staff. However, the failure to update Resident #27's EMR and ensure consistency across the care plan and physical chart resulted in a significant risk of administering unwanted CPR, violating the resident's rights. Interviews with the resident's family member confirmed the desire for the DNR to remain in place, highlighting the facility's oversight in honoring the resident's end-of-life wishes.
Expired Medication Found on Hall 100 Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that the medication cart for hall 100 was free of expired medications. During an observation, a bottle of over-the-counter medication labeled Acetaminophen 500 mg/Diphenhydramine HCl 25 mg was found on the cart with an expiration date of 11/2024, which had already passed. RN B, who was present during the observation, confirmed the expiration and stated that expired medications should not be on the cart. RN B, who had been employed at the facility for only a few months, was unsure of the frequency of audits conducted by nursing administration to check for expired medications. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that neither was aware of the expired medication on the cart. Both stated that it was the responsibility of the nursing staff to ensure expired medications were removed. The facility's policy on medication labeling and storage indicated that nursing staff are responsible for maintaining medication storage areas and contacting the dispensing pharmacy for instructions on handling expired medications. The presence of expired medication on the cart could lead to residents not receiving the full therapeutic effect of their prescribed medications.
Improper Medication Storage on Hall 100 Cart
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals in the medication cart for Hall 100, as observed during a survey. Two loose pills were found in the drawer of the medication cart, identified as Furosemide 40 mg and Cyclobenzaprine 10 mg. RN B, who was responsible for checking the cart for proper medication storage, was unaware of how the pills became loose and acknowledged that it was her duty to ensure medications were stored correctly. She had received training on proper medication storage but was not informed about the frequency of such training at the facility. The Director of Nursing (DON) and the Administrator (ADM) were also unaware of the loose pills on the medication cart. Both stated that it was the responsibility of the nursing staff and administration to ensure proper medication storage. The facility's policy on medication labeling and storage emphasized the importance of storing medications in their original packaging and maintaining a clean and orderly storage area. The policy also required that each resident's medications be stored separately to prevent mixing. Despite these guidelines, the presence of loose pills on the cart indicated a lapse in adherence to the facility's medication storage policy.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff and residents. RN C did not perform hand hygiene between glove changes during wound care for a resident with a stage 2 pressure ulcer. This resident, a male with diagnoses including adult failure to thrive, anxiety, dementia, and hypertension, was admitted with a pressure ulcer that required daily cleansing and dressing. During the wound care procedure, RN C changed gloves without sanitizing her hands, which she later acknowledged as a lapse in protocol. Another incident involved CNA E, who did not wear a gown while providing catheter care to a resident on Enhanced Barrier Precautions (EBP). This resident, a female with Parkinson's Disease, dementia, hypertension, anxiety, and an overactive bladder, required daily catheter care. Despite a sign indicating the need for gown and gloves, CNA E only wore gloves during the procedure. She later admitted to the oversight, recognizing the importance of wearing a gown to prevent infection. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of these lapses in protocol. Both acknowledged the importance of proper hand hygiene and EBP adherence, emphasizing that staff should be trained and follow these protocols consistently. The facility's policy on EBPs, revised in March 2024, outlines the necessity of using gowns and gloves during high-contact care activities to prevent the transmission of multi-drug resistant organisms.
Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to provide education regarding pneumococcal immunization and did not document evidence of receiving, refusal, or education regarding pneumococcal immunization for two residents. Additionally, the facility did not document the influenza immunization status for these residents, placing them at risk for infections and decreased quality of life. The residents involved were a female with dementia and a male with depressive episodes, dysphasia, cognitive communication deficit, reduced mobility, and aphasia, both of whom had severely impaired cognition. Interviews with facility staff, including the MDS Coordinator, DON, ADM, and ADON, revealed a lack of awareness and accountability regarding the immunization process. The MDS Coordinator and DON were unaware of any residents missing immunizations, while the ADM and ADON acknowledged the responsibility of offering immunizations but could not provide reasons for the oversight. The ADON, responsible for monitoring immunizations, stated that a list was made and given to nurses to offer and administer the immunizations, but this process failed for the two residents in question. The facility's policy required offering the influenza vaccine annually to all residents and employees without medical contraindications, with documentation of refusal placed in the resident's medical record. However, the policy was not followed, as evidenced by the lack of documentation and offering of the influenza vaccine to the two residents. The failure to adhere to the policy and ensure proper documentation and offering of immunizations led to the deficiency identified in the report.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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