Mystic Park Nursing & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 8503 Mystic Park, San Antonio, Texas 78254
- CMS Provider Number
- 676012
- Inspections on file
- 36
- Latest survey
- April 3, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Mystic Park Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Inaccurate MDS Pain Medication Coding: A resident with diagnoses including stroke, DM2, PTSD, anxiety, HTN, and spinal stenosis had a quarterly MDS that coded no scheduled pain medication use even though the MAR showed he received scheduled Tramadol three times daily and the care plan identified pain medication therapy. The MDS LVN acknowledged the resident should have been coded for scheduled pain medication, and the DON stated MDS assessments should accurately reflect the resident’s status.
A resident with MDD, PTSD, anxiety, and other psychiatric history was not referred for PASRR review despite active diagnoses documented in the MDS, care plan, physician notes, behavioral health notes, and psychiatry follow-up. Staff stated they did not usually complete a PL1 for MDD and would only do one for certain diagnoses or if the resident had behaviors, even though the facility policy required accurate PASARR screening for residents with mental disorders and a new PASRR evaluation when condition changes significantly.
Improper incontinent care and infection control occurred when a CNA cleaned a resident’s penis using one disposable wipe for several passes instead of using a different wipe for each stroke. The resident was frequently incontinent of bowel and bladder, had a hx of UTI, and required substantial to maximal assistance with toileting hygiene. The DON confirmed that using a wipe more than once during perineal care was an infection control issue.
Medication Found on Floor Near Nurse Cart: A blue pill was observed lying on the floor by the 200 hall nurse cart during surveyor observation of medication storage. NA A, an MDS LVN, the RN responsible for the cart, and the DON all stated the pill should not have been on the floor, noting it could be picked up by anyone and should be discarded. Facility policy stated drugs and biologicals are to be stored in locked compartments and kept in their containers.
Dietary staff lacked a current food handler cert for 1 of 11 staff reviewed. An employee was observed in the kitchen cleaning equipment and stated he would be preparing pure diets later that morning. The DS said the only cert on file was the one posted on the wall, while the Administrator later said HR had provided a current cert; however, online verification showed the cert had expired. The facility policy stated the dietary manager was responsible for ensuring dietary staff certs were current.
Kitchen Food Safety Deficiencies: Dish racks were observed on the floor next to the sink instead of being stored off the floor, and the deep fryer contained dark brown oil with visible food particles, sediment, and residue buildup. The DS stated the racks should be stored on a pallet when not in use and said the fryer was cleaned on a weekend schedule, while the facility policy required racks to be stored off the floor and the fryer to be cleaned regularly per manufacturer guidance.
Improper Dumpster Area Sanitation: An observation of Dumpster #1 found dried food debris and spilled waste on the ground, stained concrete around the dumpster, pest control traps stored on the ground nearby, and the drain opening missing a plug. The DS said he was unaware of the debris and missing plug, while the MS said the area was cleaned periodically, the traps were supposed to be picked up by the pest control company, and the drain plug was the responsibility of waste management.
Incomplete and inaccurate PASRR Form 1012 documentation was found for two residents. One resident’s form had missing Yes/No selections, missing onset dates, an incomplete physician signature area, and no entry in the nursing facility action section. The other resident’s form had a missing physician signature date and printed name, omitted several mental health diagnoses listed in the chart, and also left the nursing facility action section blank. Staff interviews showed uncertainty about how the forms were completed and why information had been added years after physician signature.
Hand hygiene and aseptic technique were not followed during medication administration for three residents. An LVN gave PEG-tube medication to a resident with seizures and dementia without sanitizing hands between glove changes or after touching the bed remote and bedside table, a Med Aide applied a lidocaine patch to a resident with diabetes and osteoarthritis without hand hygiene after preparing meds and drawing the curtain, and an LVN inserted a needle into a resident’s insulin pen without cleaning the rubber seal with alcohol first.
The facility failed to follow professional standards for food service safety, as dietary aides improperly handled dishes, risking contamination. Additionally, a sandwich in a resident's refrigerator was unlabeled and undated, contrary to facility policy. The resident, with severe cognitive impairment, was at risk of receiving incorrect or expired food. Staff acknowledged the importance of proper food handling and labeling, highlighting the oversight.
Staff on the 200 unit failed to knock before entering residents' rooms, violating their rights to dignity and respect. A CNA and the MDS Nurse were observed entering rooms without knocking, contrary to facility policy. A resident reported discomfort with staff entering unannounced, especially while sleeping.
The facility failed to ensure accurate MDS assessments for three residents, leading to discrepancies in documentation. A resident was incorrectly noted as receiving insulin, another was inaccurately documented as not receiving hospice care, and a third was wrongly recorded as discharged to a hospital instead of a foster home. These errors were confirmed through interviews and record reviews, highlighting a lack of understanding and attention to detail by the staff.
A facility failed to provide adequate incontinence care for a resident with severe cognitive impairment and bowel and bladder incontinence, as a CNA did not properly clean the resident's right buttock area after a bowel movement. Additionally, another resident with an indwelling urinary catheter had their catheter drainage bag and tubing touching the floor, posing an infection control risk. These deficiencies could lead to cross-contamination and urinary tract infections.
Expired medications were found in two nursing carts, including Dakin's solution and Urea 20 cream, which were not removed as per facility policy. A resident with multiple health conditions was at risk due to the presence of expired medication. Nurses acknowledged the oversight, and the DON confirmed the responsibility to discard expired medications.
A CNA failed to adhere to Enhanced Barrier Precautions by not wearing a gown while providing suprapubic catheter care to a resident with severe cognitive impairment and multiple medical conditions. Despite a posted sign indicating the need for gloves and a gown, the CNA only wore gloves, potentially risking cross-contamination and infection. The DON confirmed the breach in protocol, which is part of the facility's infection control policy.
Two residents in a shared room experienced a persistent strong odor of urine, despite the room being on a twice-daily cleaning schedule. One resident, frequently incontinent, was observed in a low bed without sheets, and the floor mat was wet with liquid smelling of urine. Staff confirmed the room was cleaned regularly, but the odor persisted, indicating a failure to maintain a sanitary and comfortable environment.
The facility failed to report alleged violations and incidents involving two residents. One resident had unexplained abrasions attributed to EPS movements, which were not reported to HHSC. Another resident experienced an unobserved fall and was sent to the hospital due to anticoagulant use, but the incident was not reported. Staff relied on a provider letter for guidance, believing the incidents did not require reporting, potentially compromising resident safety.
A facility failed to meet the pharmaceutical needs of a resident due to several critical deficiencies. The facility did not clarify orders for Digoxin regarding necessary parameters and labs, did not ensure a pharmacist performed a medication review every 30 days, and failed to monitor Digoxin levels as there was no order for it. This resulted in the resident experiencing nausea multiple times and eventually requiring hospitalization due to digoxin toxicity. The pharmacist did not advise changes to the Digoxin regimen, citing hospice services typically did not require labs for such medications, and did not conduct a pharmacy review during a month when the resident was frequently hospitalized. Staff members acknowledged the lack of monitoring and parameters for Digoxin, noting deviations from standard practices. The facility's policy on Pharmaceutical Services was not effectively implemented in this case, leading to the identified deficiencies.
A facility's failure to collaborate effectively with hospice representatives and coordinate care planning led to a resident experiencing digoxin toxicity and subsequent hospitalization. The facility did not contact the hospice medical physician or nurse to clarify orders for Digoxin, resulting in a lack of parameters and lab monitoring. Clinical notes and interviews with staff, including the DON and admitting nurse, revealed discrepancies in medication management and a breakdown in communication regarding the absence of monitoring parameters for Digoxin.
Inaccurate MDS Pain Medication Coding
Penalty
Summary
The facility failed to ensure Resident #88’s quarterly MDS assessment accurately reflected his status by not documenting his scheduled pain medication use. Resident #88 was a male resident with diagnoses including cerebral infarction, type 2 diabetes mellitus, MDD, spinal stenosis, PTSD, anxiety, and hypertension. His quarterly MDS assessment dated 01/05/2026 documented a BIMS score of 15 and recorded “0. No” for J0100A, indicating he had not received a scheduled pain medication regimen in the last 5 days. Record review showed Resident #88 had an active order for Tramadol 50 mg by mouth three times daily for spinal stenosis, and the January 2026 MAR documented that he received Tramadol as prescribed during the lookback period from 01/01/2026 through 01/05/2026. His care plan also identified that he was on pain medication therapy for spinal stenosis, hemiplegia, and hemiparesis. During interview, the MDS LVN stated the resident should have been coded for scheduled pain medication because he was receiving it, and the DON stated the MDS assessments should be accurate and reflect a clear picture of the resident.
Failure to Coordinate PASRR Review for Resident With MDD and PTSD
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for Resident #88 and did not refer the resident to the appropriate state-designated mental health authority for review despite diagnoses of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD). Resident #88’s record showed an admission history that included stroke, type 2 diabetes mellitus, MDD, spinal stenosis, PTSD, anxiety, and hypertension. The quarterly MDS documented a BIMS score of 15, and Section I listed depression and PTSD as active psychiatric/mood disorders. The resident also had an active order for Celexa 10 mg daily for depression and was receiving it as ordered on the January 2026 MAR. Additional record review showed care plans addressing risk for retraumatization related to PTSD and a mood problem related to major depressive disorder and anxiety disorder. Physician and behavioral health documentation described increased yelling out, impulsivity, mood changes, delusions, increased anxiety, being easily angered, disoriented, withdrawn, and a psychiatric history with extensive treatment and hospitalizations. Psychiatry follow-up also listed major depressive disorder and chronic PTSD as active medical problems. During interviews, MDS staff stated they did not usually complete a PL1 for MDD, that PTSD could be case-by-case, and that they would not do a PL1 if the resident was not having behaviors. The facility policy stated it was the facility’s policy to complete an accurate PASARR screening for individuals with a mental disorder and that a new PASRR evaluation is required if a resident’s condition changes significantly.
Improper Incontinent Care and Infection Control During Perineal Cleaning
Penalty
Summary
The facility failed to ensure proper incontinent care for a resident who was frequently incontinent of bowel and bladder and had diagnoses including obstructive and reflux uropathy, benign prostatic hyperplasia with lower urinary tract symptoms, and a history of urinary tract infections. The resident’s quarterly MDS reflected moderate cognitive impairment and substantial to maximal assistance needed for toileting hygiene. The care plan directed staff to check for incontinence, wash, rinse, and dry soiled areas, and provide antibiotic therapy as ordered related to a urinary tract infection. During an observation of incontinent care, CNA D cleaned the resident’s penis by making several passes with one disposable wipe in a back-and-forth motion. During a joint interview, CNA E stated she observed CNA D make more than one pass with one disposable wipe, and both CNAs stated that using a disposable wipe more than once was a break in infection control and cross contamination. The DON stated that a disposable wipe should only be used once and then discarded, and that using it for more than one pass was an infection control issue and could result in the resident getting an infection. The facility policy required washing the peri area using front-to-back strokes, and CNA D’s competency training instructed staff to use a different wipe for each stroke.
Medication Found on Floor Near Nurse Cart
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles when a blue pill was found lying on the floor by the 200 hall nurse cart. The observation was made on 3/31/26 at 10:24 AM during surveyor review of medication storage practices, and the pill was identified by staff as appearing to be a medication. The finding involved 1 of 4 medication carts observed for medication storage. During interviews, NA A stated the item looked like a medication lying on the ground, and MDS LVN B stated the blue pill should not have been on the floor for patient safety and that it should have been picked up. RN J, who was responsible for the 200-hall nurse cart, stated the pill should not be lying on the floor because anyone could pick it up and it should be discarded. The DON also stated there should not be pills on the floor and that if a pill is on the floor, it should be discarded in the proper way. Facility policy titled Medication Access and Storage stated that drugs and biologicals are to be stored in locked compartments under proper temperature controls and kept in their containers.
Dietary Staff Lacked Current Food Handler Certification
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. The facility failed to employ sufficient staff with the appropriate competencies and skill set to carry out food and nutrition services for 1 of 11 dietary staff reviewed. Specifically, [NAME] I did not have a current Food Handler Certificate. Record review showed a Texas Food Manager Certification Program certificate dated 03/03/2021 with a handwritten expiration date of 03/03/2026 and the handwritten word "Keyed" with a check mark on the document. The facility staff list showed [NAME] I was hired on 06/18/25. During observation on 3/31/26 at 9:15 a.m., [NAME] I was in the kitchen cleaning a microwave and stated he would be preparing pure diets around 11 a.m. that morning. During interviews on 04/02/26, the DS stated the only food handler certificate he had for [NAME] I was the one hanging on the wall dated 03/03/2021 and that all staff were expected to have current food handlers certificates if they were working in the kitchen. The Administrator later stated HR had provided a current certificate, but record review of the online database showed the certificate number belonged to [NAME] I, with a course name of Texas Food Manager Exam English, an issue date of 03/02/2021, and an expiration date of 03/01/2026. The facility policy stated the dietary manager was responsible for ensuring food handler certifications were current for dietary staff.
Kitchen Food Storage and Fryer Oil Maintenance Deficiencies
Penalty
Summary
The facility failed to store dish racks off the floor in the kitchen. During an observation on 03/31/26 at 9:23 a.m., one dish rack with two other dish racks on top of it was directly on the floor next to the sink. During the same observation, the DS stated the dish racks should not be on the floor and should be stored on top of a pallet when not in use because the floor was dirty. Record review of the facility policy titled Dish Handling stated that after dish racks have been emptied, racks must be stored off of the floor. The facility also failed to maintain the deep fryer oil in accordance with its cleaning practices. During an observation on 3/31/26 at 9:31 a.m., the deep fryer contained oil that was dark brown with visible food particles and sediment throughout, was not transparent, and obscured visibility to the bottom of the fryer; residue buildup was noted along the interior surfaces. The DS stated he cleaned the fryer every weekend and last cleaned it on 3/29/26, and said it was normal for the oil to get that dark because it was used to fry a lot of food for residents. A later observation on 04/02/26 showed the fryer oil appeared light in color and transparent with very little visible debris, and the DS stated the fryer had been cleaned and the oil changed on 3/31/26. Record review of the Weekly Deep Cleaning Schedule for March 2026 showed fryer oil changes and cleaning entries, and the facility policy titled Deep Fryer Cleaning Policy & Procedure stated the deep fryer would be cleaned on a regular basis as recommended by the manufacturer.
Improper Dumpster Area Sanitation
Penalty
Summary
Dispose of garbage and refuse properly. During an observation of Dumpster #1, the exterior dumpster area had visible dried food debris and spilled waste on the ground next to the dumpster, and the surrounding concrete surface had multiple darkened stains and residue. Several pest control traps were observed stored directly on the ground adjacent to the dumpster, and the drain opening at the bottom of the dumpster was not sealed with a plug. During interview, the DS stated he was unaware of the food spilled by the dumpster and said it may have just happened, although the surveyor pointed out that the food appeared dried up and contained rice and a fry. The DS also stated he was unsure why the pest traps were stored outside the dumpster and was unaware the drain plug was missing. The MS stated he cleaned and pressure washed the dumpster area every 6 months and had cleaned it again that week, that some stains were oil from the dumpster trucks, that the traps were supposed to be picked up by the pest control company but were not, and that the drain plug was supplied by waste management and was their responsibility to place on the dumpster. Record review of the facility policy titled Waste Management and Cleaning stated the dumpster area is to be observed daily by the plant team between breakfast and lunch, with maintenance/housekeeping concerns reported to the appropriate department and the perimeter area checked daily for odors and excess waste.
Incomplete and Inaccurate PASRR Form 1012 Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents on Mental Illness/Dementia Resident Review (Form 1012) documents. For one resident, the form showed a dementia review with physician attestation, but the mental illness section was incomplete because not all diagnoses had Yes or No selections, onset dates were missing for applicable diagnoses, the physician signature and date were not completed in that section, and the nursing facility action section did not indicate whether the PASRR Level 1 remained negative or whether a new Level 1 screening had been submitted. The resident’s record included diagnoses of schizophrenia, major depressive disorder, and dementia, and the MDS showed moderate cognitive impairment, depression, schizophrenia, and non-Alzheimer’s dementia. For the second resident, the Form 1012 also contained incomplete and inconsistent entries. The dementia section included a diagnosis date and the physician attestation area, but the physician signature date was not completed and the physician’s printed name was missing. In the mental illness section, schizoaffective disorder and bipolar disorder were identified, but other diagnoses in the medical record, including psychosis, mood disorder, depressive episodes, and generalized anxiety disorder, were not indicated on the form. The nursing facility action section was also left blank regarding whether the PASRR Level 1 remained negative or whether a new screening had been submitted. The resident’s record showed diagnoses of schizoaffective disorder, bipolar type, dementia, psychosis, bipolar disorder, depressive episodes, mood disorder, and generalized anxiety disorder, and the MDS reflected moderate cognitive impairment, anxiety, depression, bipolar disorder, psychotic disorder, and non-Alzheimer’s dementia. During interview, the MDS LVN stated the 1012 forms had been completed by another staff member who no longer worked at the facility and said he was unsure why information had been added to one resident’s form years after it had been signed by the doctor. He stated he understood the form was valid if a doctor signed it and said both residents had dementia as a primary diagnosis, so their PASRR Level 1 screens were answered no for mental illness and a 1012 form was completed instead. The DON stated she was unsure whether the 1012 forms were completed correctly and needed to ask her resource. During a later interview, the PASRR assessor stated that if a resident had a primary diagnosis, a new 1012 did not need to be completed if a new mental illness diagnosis was added, that it did not matter how much time had passed as long as the physician signed the 1012, and that the facility should not have added information to the forms years later.
Hand Hygiene and Insulin Pen Cleaning Not Followed During Medication Pass
Penalty
Summary
The facility failed to maintain its infection prevention and control program during medication administration for three residents. During a medication pass for a resident with seizures, dementia, and gastrostomy status, an LVN prepared levetiracetam for PEG-tube administration, then returned to the bedside, drew the privacy curtain, and put on gloves without washing or sanitizing hands. While wearing gloves, the LVN handled the resident’s bed remote and bedside table, removed the gloves, then put on another pair of gloves without hand hygiene before administering the medication through the gastrostomy tube. The LVN stated she had forgotten to sanitize her hands between glove changes and when touching the bed remote and bedside table. During a medication pass for a resident with diabetes, infection following a procedure, and osteoarthritis, a Med Aide administered oral medications, obtained a lidocaine patch and gloves, and placed them on the bedside table. The Med Aide then drew the privacy curtain, did not wash or sanitize her hands, and put on gloves before applying the patch to the resident’s left shoulder. The Med Aide stated she forgot to sanitize her hands after preparing the medications and after drawing the curtain, and stated hand hygiene should have been performed before putting on gloves because of cross contamination and the possibility of infection being passed to the resident or other residents. For a resident with type 1 diabetes, long-term insulin use, heart failure, end stage renal disease, and dependence on renal dialysis, an LVN retrieved the resident’s insulin pen from the medication cart and inserted a needle into the pen without sanitizing the rubber seal with an alcohol swab. The LVN stated she had forgotten to sanitize the rubber seal before inserting the needle and before injecting insulin, and stated cleaning the seal was important to prevent contamination because the seal is punctured with a needle used on the resident. The DON stated the rubber seal of an insulin pen was supposed to be cleaned with an alcohol swab prior to inserting the needle to prevent cross contamination and that cross contamination could cause infection.
Improper Food Handling and Labeling in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen and a resident's personal refrigerator. Dietary Aides were seen handling dishes improperly, touching the inside rims of plates and cups, which could lead to contamination. Despite being trained, the aides were observed making these errors, and the Dietary Supervisor acknowledged the risk of contamination and foodborne illnesses due to these practices. Additionally, a sandwich provided by the facility was found in a resident's personal refrigerator without a label or date. The resident, who had severe cognitive impairment and required assistance with eating, had a sandwich stored in a manner that did not comply with the facility's policy. The lack of labeling and dating could result in the resident receiving an incorrect diet texture or consuming expired food, potentially leading to foodborne illness. Interviews with staff, including the Dietary Supervisor and the Director of Nursing, confirmed the importance of proper food handling and labeling. The staff acknowledged the oversight in labeling the sandwich and the potential risks associated with improper food storage and handling. The facility's policy requires that all food brought to residents be inspected and properly labeled, which was not followed in this instance.
Failure to Knock on Residents' Doors
Penalty
Summary
The facility failed to uphold the residents' rights to dignity and respect by not ensuring staff knocked before entering residents' rooms. This deficiency was observed on the 200 unit, where both a CNA and the MDS Nurse entered multiple resident rooms without knocking. Specifically, CNA K was seen entering several rooms without knocking, including moving furniture and straightening up rooms, while the MDS Nurse also entered a room without knocking. During interviews, CNA K acknowledged the importance of knocking for privacy, while the MDS Nurse denied failing to knock. Resident #25, a cognitively intact male with mobility issues, reported that staff sometimes entered his room without knocking, which he found unsettling, especially when he was asleep. The facility's policy on Resident Rights, Dignity, and Respect mandates that staff knock before entering a resident's room, highlighting a discrepancy between policy and practice. The DON stated that staff should knock if they know a resident is in the room, but if the resident is known to be elsewhere, entering without knocking was deemed acceptable.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) documentation. Resident #61's MDS inaccurately indicated that he received insulin injections, although he was only treated with Metformin and Trulicity, which is not an insulin. Interviews with the resident, LVN, DON, and MDS Nurse confirmed the error, highlighting a lack of understanding about the medication by the staff involved. Resident #148's admission MDS incorrectly stated that he was not receiving hospice care, despite being admitted to the facility on hospice services. The comprehensive care plan and physician orders confirmed the resident's hospice status, but the MDS Nurse admitted to mistakenly coding the MDS, which did not reflect the resident's actual care needs. Resident #95's discharge MDS inaccurately documented that he was discharged to a hospital, while records and interviews confirmed he was discharged to a foster home. The MDS Nurse acknowledged the error, emphasizing the importance of accurate MDS documentation for determining resident status and facility reimbursement. These inaccuracies in MDS assessments could potentially lead to inadequate care and services for the residents involved.
Inadequate Incontinence and Catheter Care
Penalty
Summary
The facility failed to provide appropriate incontinence care for Resident #27, who was always incontinent of bowel and bladder and had severe cognitive impairment. During an observation, CNA-E did not adequately clean the resident's right buttock area after a bowel movement. Although CNA-E cleaned the resident's left buttock and middle area, including the anus, she did not turn the resident to his left side to clean the entire right buttock area. This oversight was acknowledged by CNA-E, who admitted that she thought a single wipe was sufficient. The Director of Nursing (DON) confirmed that the resident should have been turned to ensure complete cleaning to prevent possible unclean status. The facility also failed to ensure proper catheter care for Resident #82, who had an indwelling urinary catheter due to obstructive and reflux uropathy. During an observation, the resident's catheter drainage bag and tubing were found touching the floor while she was seated in a wheelchair. LVN M, upon being informed by the State Surveyor, acknowledged that the catheter bag and tubing should not be on the floor due to infection control concerns and the risk of kinking, which could impede urine flow. The DON reiterated that the catheter and tubing should not touch the floor to prevent infection and potential urine retention. These deficiencies in care could place residents at risk for cross-contamination and the development of urinary tract infections. The facility's policies on incontinence care and catheter care were not adhered to, as evidenced by the observations and interviews conducted during the survey.
Expired Medications Found in Nursing Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medications from nursing carts, as observed in two instances. On January 22, 2025, a bottle of Dakin's solution, which expired in November 2024, was found in the 300-hall nursing cart. A nurse acknowledged the presence of the expired medication and admitted that it should have been discarded according to facility policy. The potential harm identified was the risk of using expired medication, which might not have therapeutic effects. Additionally, a cream of Urea 20 intensive Hydrating cream, expired on November 13, 2024, was found in the 200-hall nursing cart. This medication was intended for a resident with a history of hemiplegia, type 2 diabetes, hypertension, and a risk of developing pressure ulcers. The nurse confirmed the expired medication's presence and acknowledged that it should have been removed. The Director of Nursing reiterated that nurses are responsible for discarding expired medications from the carts, as per the facility's policy.
Infection Control Breach During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a male with severe cognitive impairment and multiple medical conditions including anoxic brain damage, quadriplegia, epilepsy, acute respiratory failure, and acute kidney failure, required suprapubic catheter care. Despite a posted sign indicating the need for gloves and a gown during high-contact care activities, the CNA entered the resident's room, sanitized her hands, and donned gloves but failed to wear a gown while performing the catheter care. The CNA acknowledged her failure to wear a gown, attributing it to nervousness and forgetfulness, and recognized the potential risk of infection to the resident. The Director of Nursing (DON) confirmed that the CNA should have worn a gown in accordance with the facility's infection control policy, which mandates the use of gloves and gowns during high-contact activities such as catheter care. This oversight in following established protocols could lead to cross-contamination and infections, compromising the safety and well-being of residents requiring assistance with treatments.
Failure to Maintain a Sanitary and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for two residents sharing a room, as evidenced by a persistent strong odor of urine. Observations revealed that the room had a strong urine smell, particularly on one resident's side, and the floor mat was found to be wet with standing liquid that smelled of urine. Despite the room being on a twice-daily cleaning schedule, the odor persisted, and the cleaning solutions used were the same as those for other rooms. One resident, who was frequently incontinent of urine and bowel, was observed in a low bed on the floor without sheets, and the mattress was slightly away from the wall. The resident's care plan included interventions for incontinence and potential behavior problems, such as urinating in common areas or in bed. The other resident, who was severely cognitively impaired and also frequently incontinent, was observed in bed watching TV during one of the visits. Interviews with staff, including the DON and housekeeping employees, confirmed that the room was cleaned twice daily and as needed due to the resident urinating on the floor. The fall mat was replaced when wet, and the room was cleaned with the same solutions as other rooms. Despite these efforts, the strong urine odor persisted, indicating a failure to maintain a sanitary and comfortable environment for the residents.
Failure to Report Alleged Violations and Incidents
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframes. Specifically, the facility did not report an incident involving a resident who was found with abrasions on her right shoulder and elbow. These injuries were not witnessed and were attributed to the resident's extrapyramidal side effects (EPS) movements. Despite the facility's internal assessment, the injuries were not reported to the Health and Human Services Commission (HHSC) as required, which could have ensured a proper investigation into the cause of the injuries. Another incident involved a resident who experienced an unobserved fall and was subsequently sent to the hospital for evaluation. The resident was on an anticoagulant, which necessitated a hospital evaluation to rule out any potential bleeding. The facility did not report this fall to the HHSC, citing guidance from a provider letter that suggested such incidents did not require reporting if they were not suspicious or of unknown source. However, the lack of reporting could have prevented a thorough investigation into the circumstances surrounding the fall. Interviews with facility staff, including the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), revealed a reliance on the updated provider letter for guidance on reporting requirements. The staff believed that the incidents did not meet the criteria for mandatory reporting. However, the failure to report these incidents to the appropriate authorities could have compromised the health and safety of the residents by not ensuring a comprehensive investigation into the causes of the injuries and fall.
Deficiencies in Pharmaceutical Services and Digoxin Monitoring
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of one resident (Resident #1) due to several critical deficiencies. Specifically, the facility did not clarify orders for Digoxin regarding the need for parameters and labs, did not ensure the pharmacist performed a medication review every 30 days, and failed to monitor Resident #1's Digoxin levels as there was no order for it. This led to Resident #1 experiencing nausea multiple times and eventually requiring hospitalization due to digoxin toxicity, with elevated digoxin levels indicating a serious health risk. The facility's pharmacist did not advise any changes to the Digoxin regimen during a review, citing that hospice services typically did not require labs for such medications. Additionally, the pharmacist did not conduct a pharmacy review for Resident #1 in March 2024, as the resident was in and out of the hospital. The facility's policy on Pharmaceutical Services outlined the importance of accurate acquiring, receiving, dispensing, and administering of drugs but was not effectively implemented in Resident #1's case, leading to the identified deficiencies. During interviews, staff members acknowledged the lack of monitoring and parameters for Resident #1's Digoxin, with the admitting nurse and pharmacist both noting deviations from standard practices. The facility's failure to ensure proper medication monitoring and review processes for Resident #1 resulted in a critical deficiency that put the resident at risk of adverse health outcomes, including hospitalization and potential harm.
Coordination and Monitoring Gaps in Hospice Care for Digoxin Management
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to collaborate with hospice representatives and coordinate hospice care planning for a resident (Resident #1) receiving hospice services. Specifically, the facility did not contact the hospice service medical physician or nurse to clarify physician orders for Digoxin, leading to a lack of parameters and lab monitoring for potential toxicity. This failure resulted in the resident experiencing digoxin toxicity, leading to hospitalization for complaints of nausea. The report highlighted that the hospice physician did not typically order parameters or labs for digoxin and acknowledged the need for improved communication and monitoring in such cases. The deficiency was further underscored by the facility's admission sheet and clinical notes, which revealed discrepancies in the monitoring and management of Resident #1's medications, particularly Digoxin. Despite the resident's complaints of nausea and hospitalization due to digoxin toxicity, the facility did not have appropriate parameters or lab orders in place for monitoring the resident's condition. Interviews with staff members, including the Director of Nursing (DON) and admitting nurse, indicated a lack of questioning or clarification regarding the absence of parameters for digoxin, highlighting a breakdown in communication and oversight in the care planning process for hospice residents.
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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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