The Colonnades At Reflection Bay
Inspection history, citations, penalties and survey trends for this long-term care facility in Pearland, Texas.
- Location
- 12001 Shadow Creek Parkway, Pearland, Texas 77584
- CMS Provider Number
- 676207
- Inspections on file
- 48
- Latest survey
- May 1, 2026
- Citations (last 12 mo.)
- 21 (3 serious)
Citation history
Health deficiencies cited at The Colonnades At Reflection Bay during CMS and state inspections, most recent first.
Unlabeled medications were found on 3 medication carts, including Lantus insulin, mupirocin ointment, Nuedexta, and tetrahydrozoline eye drops, all without resident-specific information. Staff stated the medications should have been labeled with the resident's name and DOB or other resident information before administration, and the Unit Manager said medications should always be labeled so they could be administered correctly.
A resident with a BIMS of 15 and diagnoses including bipolar disorder and anxiety disorder was involved in a medication administration incident after she became upset about a delayed PRN pain med. The nurse later returned with a CNA as a witness, poured the meds into the resident's mouth, and asked her to open her mouth to prove she swallowed them. The resident said the interaction made her feel like she was in prison, and the CNA confirmed the events.
A resident with polyneuropathy, DM2, UTI, and HTN was discharged without a reconciled med list, discharge paperwork, or her prescribed meds, including pain meds. The discharge summary had no current meds listed, the signed discharge instruction form was not found in the chart, and the resident reported she went overnight without meds until the discharge planner delivered them the next morning. Staff accounts conflicted about whether discharge instructions and meds were reviewed and provided.
Inaccurate PASRR Level 1 Screening for Resident With Schizophrenia: A resident admitted with schizophrenia, dementia, epilepsy, and stroke-related deficits was screened as negative for MI, ID, and DD despite an active schizophrenia dx, antipsychotic use, severe cognitive impairment on MDS, and a care plan for behavioral issues. The MDS Coordinator said she did not verify the PASRR accuracy and was unsure whether the resident had been referred to psychiatry.
Foley Catheter Bags Not Emptied as Ordered: Two residents with indwelling Foley catheters had drainage bags observed more than half full, despite orders to empty them every shift or every 4 hours. Staff interviews showed CNAs and nurses were responsible for emptying and reporting output, but the bags had not been emptied as expected and one CNA did not report the output to the nurse.
A resident with COPD and chronic respiratory failure who used O2 via nasal cannula was found with an oxygen concentrator showing a red malfunction light, no flow on the meter, and a beeping alarm for hours. The resident reported not getting enough air, and when the nurse responded he adjusted the flow dial but did not know why the alarm was sounding. The resident’s SpO2 dropped from her usual upper-90s baseline to 91%-93% after the concentrator was checked.
Surveyors found that several medication carts were left unlocked and unattended, with drawers open and keys accessible, while multiple insulin and heparin vials were undated and unlabeled. Staff interviews confirmed that carts should be locked and medications properly labeled, but these practices were not consistently followed.
Sharps containers in two resident bathrooms were found filled above the full line, with staff interviews revealing unclear responsibility and lack of a specific policy for timely replacement. Nursing staff indicated they were responsible for monitoring and changing the containers, while housekeeping staff did not have access. The absence of clear procedures led to overfilled sharps containers, increasing the risk of exposure to used sharps.
A medication cart was found to contain an expired insulin vial that had not been removed as required by facility policy. Staff interviews revealed inconsistent practices regarding the dating and disposal of insulin, and the expired medication remained accessible on the cart.
A resident with dementia, end stage renal disease, and impaired mobility was able to leave the facility unsupervised on two occasions, including crossing a busy street and being found at a nearby apartment complex. Staff failed to complete elopement risk assessments or implement appropriate supervision, and there was a lack of communication and documentation regarding the incidents.
A resident with a feeding tube was laid flat by a CNA while the feeding pump was running, leading to visible aspiration of formula. The LPN present did not promptly stop the feeding or reposition the resident, and there was a significant delay in providing suctioning and assessment. Staff actions did not follow established protocols for enteral feeding and aspiration precautions, resulting in a deficiency related to failure to prevent complications of enteral feeding.
A resident with a feeding tube and multiple complex conditions was laid flat by a CNA while her feeding pump was running, leading to possible aspiration. The LPN present did not promptly intervene, failed to stop the feeding pump, and delayed suctioning, while staff interviews revealed inconsistent knowledge of enteral feeding protocols and aspiration precautions.
A resident with cognitive impairment and multiple medical conditions eloped from the facility on two occasions, but staff failed to report these incidents to the State Survey Agency as required. The facility did not complete elopement assessments or incident reports prior to the second event, and staff interviews revealed inconsistencies in recognizing and reporting the incidents, resulting in noncompliance with regulatory reporting requirements.
A resident with severe cognitive impairment and multiple complex medical conditions repeatedly refused prescribed medications, including anticonvulsants and antihypertensives, over an extended period. Although staff were aware of the refusals and communicated them internally and to the provider, the facility did not update the care plan to include measurable objectives or interventions addressing the medication refusals, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive several prescribed medications and enteral feedings on multiple occasions, as shown by blank entries in the eMAR. Nursing staff and management confirmed that these blanks indicated missed doses, and facility policy requires both administration and documentation of all medications. There was no evidence that the resident refused the medications or that the physician was notified of the omissions.
A resident repeatedly refused multiple prescribed medications, including seizure medications and supplements, over an extended period. While these refusals were recorded in the eMAR, nursing staff did not document the refusals or notify the MD, NP, or responsible party in the resident's progress notes as required. Interviews confirmed that staff were aware of the documentation and notification expectations, but these actions were not completed or recorded, and the facility could not provide a relevant documentation policy.
A resident with a documented tracheostomy was admitted without appropriate orders or documentation for tracheostomy care, despite clear hospital discharge instructions. Nursing staff and leadership could not confirm that tracheostomy care or suctioning was provided, and facility records did not reflect any such care or recent staff training on the procedure.
A resident with severe cognitive impairment and multiple wounds experienced a deterioration of a sacral pressure ulcer from stage 2 to stage 4, with delayed wound care interventions, inconsistent administration of prescribed treatments, and inadequate documentation and performance of repositioning. The wound became infected and required hospitalization for sepsis. Similar lapses in repositioning and documentation were observed for two other residents, reflecting a pattern of deficient care.
Three residents who were dependent on staff for ADLs did not consistently receive scheduled showers or bed baths, resulting in missed hygiene care over multiple days. Residents reported grievances and described staff not returning to assist with bathing, while staff interviews revealed issues with documentation and unclear responsibilities for recording care provided.
A resident with a Foley catheter and ostomy was not provided with appropriate catheter care, as the catheter bag was observed lying on the bed and hanging on the floor instead of being secured below the bladder. The resident experienced discomfort and embarrassment due to the lack of proper strapping and positioning, and staff confirmed that required practices for catheter care and resident education were not consistently followed.
A resident with severe cognitive impairment and a gastrostomy received new physician orders for tube feeding, which were administered as directed, but the care plan was not updated to include this intervention until several days later. Staff interviews revealed gaps in interdisciplinary communication and timely care plan updates, resulting in the care plan not reflecting the resident's current nutritional needs.
Two residents in a LTC facility experienced significant medication errors. One resident received morphine more frequently than prescribed, leading to excessive sedation and Narcan administration. Another resident, who was immunocompromised, missed four doses of Posaconazole due to unavailability, resulting in a hospital readmission with a fever. Staff interviews revealed communication failures and non-adherence to medication protocols.
A facility failed to maintain accurate clinical records for two residents, leading to potential delays in necessary interventions. A nurse documented nebulizer treatment details for a resident without administering the treatment, and another nurse estimated a resident's post-treatment oxygen saturation without using a pulse oximeter. The facility's policy requires accurate documentation to ensure effective communication and care.
The facility failed to adhere to Enhanced Barrier Precautions for residents requiring such measures, as staff did not wear gowns during high-contact care activities. A resident with a G-tube was transferred without proper PPE, and two residents received incontinent care without staff wearing gowns, despite the presence of precautionary signs. Interviews with facility staff confirmed the requirement for gowns during these activities to prevent MDRO transmission.
The facility failed to provide adequate respiratory care for two residents, leading to improper oxygen monitoring and documentation. A resident with COPD was documented as being on room air despite needing continuous oxygen, and low oxygen saturation levels were not reported to the physician. Another resident's oxygen saturation was inaccurately documented post-nebulizer treatment. These deficiencies highlight a lack of adherence to care protocols.
A resident with severe cognitive impairment and a history of diabetes and skin infections did not receive wound care as ordered. The Wound Care Nurse applied betadine to the resident's foot but failed to cover it with a kerlix bandage, contrary to the treatment plan. This oversight was acknowledged by the nurse and could lead to further complications.
A resident's call light was found out of reach, violating their right to reasonable accommodation. The resident, who was bedfast and had muscle weakness, could not call for assistance. Interviews with staff confirmed the oversight, and facility policies were not followed.
A resident's room was found with soiled sheets and a strong urine odor, indicating a failure to maintain a clean and homelike environment. The resident, who needed assistance due to medical conditions, was left waiting for linens to be changed. Staff interviews revealed a lack of awareness and distraction, leading to unmet needs and a breach of facility policies on resident dignity and consistent care.
The facility failed to maintain an effective pest control program, resulting in roaches being observed in a resident's room. The resident frequently saw roaches, especially when the lights were off, and expressed fear of them crawling into her bed. Despite pest control treatments in November, the issue persisted, particularly in certain halls, as acknowledged by the Administrator. The facility's policy required an ongoing pest control program to keep the building free of pests, which was not effectively implemented.
A resident with severe cognitive impairment and multiple medical conditions did not consistently receive scheduled showers and clothing changes during the 2:00 p.m. - 10:00 p.m. shift, leading to body odors and family complaints. Despite being dependent on staff for ADLs, the resident's hygiene needs were not met, and documentation did not accurately reflect the care provided. The facility's administrator acknowledged the issue but claimed showers were given the next day.
A resident with severe cognitive impairment and an indwelling catheter was found without a catheter stabilizer, risking catheter dislodgement. The CNA noted the stabilizer's adhesive was ineffective, and the LVN relied on CNAs for updates on catheter security. The DON confirmed nursing staff's responsibility to ensure catheter stabilization, as per facility policy to prevent infections.
A facility failed to maintain an effective infection prevention and control program when a CNA did not perform hand hygiene after removing soiled gloves during incontinence care for a resident with severe cognitive impairment and an indwelling catheter. The CNA touched various items in the resident's environment with soiled gloves, risking cross-contamination. Additionally, another staff member improperly used double gloves, contrary to facility policy. Interviews confirmed these actions were against infection control protocols.
A resident with severe cognitive impairment and total dependence on assistance for transfers was improperly transferred by a CNA, who lifted the resident under the arms without using a gait belt, despite another staff member being present. This incident, captured on video, violated the facility's policy requiring gait belts for transfers and was acknowledged as improper by the DON. The CNA was terminated following the incident.
A facility failed to provide proper incontinent care for a resident with dementia, leading to a deficiency. The resident required substantial assistance and was always incontinent. During care, a CNA did not properly clean the resident, failing to spread the labia and clean the urinary meatus, increasing the risk of infection. The CNA admitted to the oversight due to nervousness, and the DON confirmed expectations for complete care, though no policy was provided upon exit.
A CNA failed to perform proper hand hygiene during incontinence care for a resident with dementia and incontinence, leading to potential cross-contamination. The CNA did not wash or sanitize hands between glove changes, despite the facility's policies requiring such practices. The CNA had not completed infection control training at the facility, contributing to the deficiency.
The facility failed to maintain an effective pest control program, with observations of roaches, gnats, and flies in the kitchen, dining area, and resident rooms. Despite regular pest control treatments, staff and contractors confirmed ongoing pest issues, placing residents at risk of infection and food-borne illnesses.
Unlabeled medications found on multiple medication carts
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 3 of 6 medication carts reviewed for labeling and expired medications. On the 300 hall medication cart, a vial of Lantus 100 units/ml insulin and a tube of mupirocin ointment usp 2% were observed without resident-specific labeling. On the 600 hall medication cart, a bottle of Nuedexta 20mg/10mg was observed without resident-specific information. On the 100 hall medication cart, a bottle of tetrahydrozoline HCL 0.05% eye drops was observed without resident-specific information. During interviews, LVN A stated the Lantus and mupirocin should be labeled with the resident's name and date of birth before administration. LVN D stated the Nuedexta bottle should have been labeled with the resident's name and date of birth and that without labeling staff could not know who it belonged to. MA T stated the eye drops should be labeled with resident information because otherwise staff could not be sure who they belonged to. The Unit Manager stated medications should always be labeled with resident information or they could not be administered. The facility policy on Medication Administration required comparison of the medication source with the MAR to verify resident name, medication name, form, dose, route, and time, and the Pharmacy Services policy stated the facility would provide pharmaceutical services consistent with state and federal requirements and current standards of practice.
Resident's dignity not maintained during medication administration
Penalty
Summary
The facility failed to ensure Resident #96 was treated with respect and dignity when medication was administered on 4/15/26. Resident #96 was admitted with diagnoses including pleural effusion, interstitial pulmonary disease, bipolar disorder, neuropathy, and anxiety disorder. Her MDS assessment showed a BIMS of 15, indicating no cognitive impairment, and she had no functional impairments of her upper extremities. The care plan noted she was receiving pain medication therapy, including Hydrocodone and Pregabalin. According to the record and interviews, Resident #96 requested PRN pain medication while the nurse was occupied with another resident's emergency. The resident became upset about the delay and was described as yelling, making threatening statements, and being verbally and physically aggressive. The nurse later entered the room to administer the medication, and the resident grabbed at the nurse, causing the medication cup and cream to fall. The nurse then backed away, called for a CNA, and asked the CNA to witness the medication administration. Resident #96 reported that the CNA poured the medication into her mouth and asked her to open her mouth to prove she had swallowed it, which made her feel like she was in prison. CNA Y confirmed that the nurse asked her to witness the administration and that the nurse poured the medication into the resident's mouth and asked her to open her mouth. The facility policy stated that employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence and to be treated with respect, kindness, and dignity.
Discharge Process Failed to Provide Reconciled Medications and Paperwork
Penalty
Summary
The facility failed to ensure a safe discharge process for a resident with polyneuropathy, type II diabetes mellitus, a urinary tract infection, and essential hypertension. The resident’s discharge MDS showed a BIMS score of 13 out of 15, indicating intact cognition, and the discharge summary noted she had received scheduled and PRN pain medication within the last 5 days and had experienced occasional mild pain. Her care plan included monitoring a raised bruise area to the right shin and giving medication per order with monitoring for relief. At discharge, the resident was sent home at 6:56 p.m., but the discharge summary’s Current Medications section contained no entries. The discharge instruction form indicated that medication education was reviewed, prescriptions were provided, and the resident acknowledged receipt of the current reconciled medications, yet no reconciled medication list was present on the form and no scanned copy of the signed form was found in the chart. The facility’s discharge documentation also reflected items such as medications called into the pharmacy, follow-up appointments, and instructions to share the medication list with health care providers, but the record did not contain the actual reconciled medication list. The resident reported she did not receive discharge paperwork, belongings, or medications when the ride arrived, and she stated she was told she could not take her medications home because they were narcotics. She said she went the remainder of the evening and the following morning without her prescribed medications, including pain medications, and did not receive them until the next morning when the discharge planner delivered them to her home. The administrator confirmed the medications were not prepared at the time of discharge and that the facility could not produce a reconciled list of medications provided to the resident. The discharge planner and nursing staff gave differing accounts of whether discharge paperwork and medications were reviewed and provided, and the facility’s transfer and discharge policy required medication reconciliation, resident orientation for discharge, and assistance with transportation arrangements.
Inaccurate PASRR Level 1 Screening for Resident With Schizophrenia
Penalty
Summary
The facility failed to accurately submit a PASRR Level 1 screening for a resident admitted with diagnoses including schizophrenia, dementia, epilepsy, hemiplegia, and hemiparesis following cerebral infarction. The PASRR Level 1 screening dated 3/27/26 identified the resident as negative for mental illness, intellectual disability, and developmental disability, despite the resident having an active diagnosis of schizophrenia and receiving Quetiapine Fumarate 50 mg via g-tube twice daily. The resident’s comprehensive MDS showed a BIMS score of 1, indicating severe cognitive impairment. Record review also showed the resident had a care plan for behavior problems, including removing a colostomy bag and throwing it on the floor, with interventions focused on anticipating needs, assisting with coping, encouraging appropriate expression of feelings, providing positive interaction, and stopping to talk when passing by. During observation, the resident was lying in bed wearing a hospital gown and watching TV, and when asked about food, repeatedly responded, "I'm alright" or "It's alright." The MDS Coordinator stated she would upload the PASRR Level 1 in the system within 72 hours, did not check whether the PASRR was accurate, and was unsure whether the resident had been referred to a psychiatrist.
Foley Catheter Bags Not Emptied as Ordered
Penalty
Summary
The facility failed to ensure appropriate catheter care and treatment for residents with indwelling Foley catheters. Resident #33 was admitted with diagnoses including sepsis, acute kidney failure, and obstructive/reflux uropathy, and her MDS coded her as always incontinent with a BIMS score of 13. Her care plan identified an indwelling Foley catheter for neurogenic bladder and directed staff to position the catheter bag and tubing below bladder level, while the clinical order required Foley catheter care, patency checks, and emptying the bag every shift. On 04/29/2026 at 11:22 a.m., Resident #33’s Foley bag was observed to be 1600 cc out of 2000 ml full. During interviews, CNA A stated she checked the bag at the beginning of her shift and usually emptied it at the end of the shift or when full. CNA B stated she emptied the bag during the night shift but did not remember whether she reported the output to the nurse. RN A and RN B both stated that CNAs and nurses were responsible for emptying the Foley bag, and they indicated that the amount observed meant the night shift did not empty it. The resident stated the Foley catheter was not emptied throughout the night. Resident #28 was admitted with neurogenic bladder, had a BIMS score of 13, was paraplegic, and had an indwelling catheter documented in the MDS. Her care plan stated she was dependent on the catheter for management of neurogenic bladder and included monitoring and reporting for signs and symptoms of UTI and catheter-related discomfort. Her clinical order and MAR directed that the Foley bag be emptied every four hours. On 04/30/2026 at 5:00 p.m., Resident #28’s Foley bag was observed to be 1500 cc out of 2000 cc full. LVN B and LVN C stated that the bag should have been emptied by the earlier shift and that the output had not been reported at shift change. CNA C stated she had emptied the bag once during her shift but did not report the reading to the nurse because she did not know she had to do so.
Failure to Maintain Functioning Oxygen Concentrator
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD and chronic respiratory failure who required oxygen via nasal cannula. Resident #93 had diagnoses including chronic respiratory failure with hypoxia, shortness of breath, hypertension, COPD, acidosis, and generalized anxiety disorder. Her care plan directed staff to provide oxygen as ordered, monitor for respiratory distress, and observe for changes such as decreased pulse oximetry, increased respirations, restlessness, and air hunger. Physician orders and respiratory documentation showed she routinely used oxygen and had baseline SpO2 readings in the upper 90s while on oxygen. On 4/28/2026, surveyors observed the resident in bed with her nasal cannula in place and the oxygen concentrator attached beside her bed. At 8:48 a.m., the concentrator had a red light illuminated next to a wrench symbol and the flow meter showed no flow. The resident stated she felt okay and believed the machine was working because she could hear it vibrating. At 2:11 p.m., the same concentrator was still showing a red light, making a humming noise, and emitting a loud beeping alarm, with the flow meter still reading below 0 lpm. The resident stated the beeping had been occurring for hours and said, "I don't feel like I'm getting enough air." When the nurse was notified, he initially remained at the nurses' station, then entered the room and adjusted the flow dial so the flow meter rose to 2 lpm, but the concentrator continued to display a red light and alarm. He stated he did not know the cause of the red light or alarm and would need to consult respiratory therapy. The resident's SpO2 was then measured at 92%, fluctuating between 91% and 93% over 1 to 2 minutes. Later that day, the resident was observed with a new oxygen concentrator and stated staff had brought it in shortly after the surveyor left the room. Staff interviews indicated a CNA had heard the beeping and reported it to the nurse, while the nurse denied hearing the alarm before the surveyor brought it to his attention. The facility's oxygen concentrator policy stated the nurse shall verify physician orders for the rate of flow and route of administration of oxygen.
Medication Carts Left Unlocked and Medications Unlabeled
Penalty
Summary
Surveyors observed that seven out of fourteen medication carts were left unlocked and unsecured when not in use, with drawers open and the key lock visibly protruding. Multiple medication carts on both the first and second floors were unattended by staff, and in one instance, the cart keys were found inside a binder on top of a cart. Staff interviews confirmed that medication carts should be locked when not in use to prevent unauthorized access. Additionally, several biologicals, including various types of insulin and heparin, were found on multiple carts without proper labeling or dating, contrary to facility policy and accepted pharmaceutical practices. Staff members, including CMAs and LVNs, acknowledged during interviews that insulins should be dated when opened and that medication carts should remain locked if not in immediate use. The facility's policy requires multi-dose vials to be dated and discarded within 28 days unless otherwise specified. Despite this, surveyors found undated and unlabeled insulin and heparin on several carts, and staff were not always present to monitor the carts, increasing the risk of improper medication handling.
Sharps Containers Overfilled in Resident Bathrooms
Penalty
Summary
Surveyors observed that two resident bathrooms contained sharps containers that were filled above the designated full line. Multiple staff interviews confirmed that the containers should be emptied when they reach the full line, but the containers in these bathrooms had not been changed as required. The responsibility for monitoring and changing the sharps containers was unclear among staff, with nursing staff indicating they were responsible, while housekeeping staff stated they did not have access to the containers. The Executive Director acknowledged there was no specific policy for emptying sharps containers and that the infection control policy did not address this issue. Staff interviews revealed inconsistent practices regarding the monitoring and replacement of sharps containers, with some staff stating they should be checked daily and changed at the full line to prevent exposure to body fluids. The lack of a clear policy and defined responsibility led to the containers being overfilled, creating an environment where residents could potentially be exposed to used sharps. The deficiency was identified through direct observation and staff interviews, with no mention of any resident being harmed at the time of the survey.
Expired Insulin Found on Medication Cart
Penalty
Summary
The facility failed to provide proper pharmaceutical services by not ensuring that a medication cart was free of expired insulin. During an early morning observation, a surveyor found an insulin vial on one medication cart that was dated as opened on 09/07, indicating it was expired. Multiple staff interviews confirmed that insulin vials are required to be dated when opened and should be removed from the cart once expired. Staff members, including LVNs and the ADON, acknowledged that expired medications should not remain on the cart and should be disposed of according to facility policy. A review of the facility's policy on medication labeling and storage indicated that outdated medications should be returned or destroyed per pharmacy instructions. Despite this policy, the expired insulin remained on the cart, and staff interviews revealed inconsistent practices regarding the handling and disposal of expired insulin. The failure to remove the expired insulin from the medication cart constituted a lapse in the facility's procedures for the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with multiple risk factors, including end stage renal disease, unspecified dementia, repeated falls, and impaired mobility. The resident, who used a wheelchair or scooter and was cognitively impaired, was able to independently ambulate and had a history of confusion and memory loss. Despite these risks, the resident was able to leave the facility without staff knowledge or supervision on two separate occasions. On one occasion, the resident was found attempting to cross a four-lane street with a posted speed limit of 50 mph, and on another, the resident was located at an apartment complex across the street after being missing for a period of time. The facility's records and staff interviews revealed that there were no elopement risk assessments completed for the resident prior to the second incident, and no interventions or increased supervision were in place despite the resident's known cognitive impairment and previous attempt to leave the premises. Staff failed to recognize or respond to the resident's elopement risk, and there was a lack of communication and documentation regarding the incidents. Multiple staff members, including nurses and the receptionist, were unaware of the resident's risk for elopement and did not have clear protocols for monitoring or restricting the resident's movements. Interviews with staff and administration indicated inconsistencies in the recognition and reporting of the elopement events. Some staff were unaware of previous incidents, and there was confusion about whether the events constituted reportable elopements. Incident reports were not completed for any of the occurrences, and there was no evidence of a thorough investigation or timely notification to facility leadership. The lack of appropriate assessment, supervision, and response to the resident's behavior directly led to the resident being able to leave the facility unsupervised on multiple occasions.
Failure to Ensure Safe Positioning and Timely Intervention During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident with a feeding tube was laid flat by a CNA while the feeding pump was actively running, contrary to the care plan and facility policy that required the head of the bed to be elevated at least 30 degrees during and after enteral feeding. The resident had significant medical conditions, including severe cognitive impairment, dysphagia, gastrostomy status, and chronic respiratory disease, making her particularly vulnerable to complications from improper tube feeding management. Video evidence showed the CNA lowering the bed and the feeding pump remaining on, with no immediate intervention to pause the feeding or reposition the resident. Shortly after being laid flat, the resident began to have a moderate amount of white fluid coming from her mouth, which appeared to be formula. The LPN present did not immediately stop the feeding pump or reposition the resident, and there was a delay in providing suctioning. The LPN was observed searching for suction equipment and did not act with urgency, resulting in a significant delay before suctioning was performed. Throughout this period, the feeding pump continued to run, and the resident was not promptly assessed for vital signs or lung sounds as required by protocol. Interviews with facility staff, including the DON and ADM, confirmed that the actions taken by the CNA and LPN did not follow established protocols for enteral feeding management and aspiration precautions. The staff failed to demonstrate a sense of urgency, did not properly assess the resident after signs of aspiration, and did not document the incident accurately. The incident was identified as Immediate Jeopardy due to the failure to provide appropriate treatment and services to prevent complications of enteral feeding, specifically aspiration.
Failure to Ensure Competency in Enteral Feeding Care Leads to Resident Harm
Penalty
Summary
Nurse aides and licensed nurses failed to demonstrate the necessary competencies and skills to safely care for a resident with a feeding tube, as identified through the resident's assessment and care plan. The resident, who had multiple complex medical conditions including gastrostomy status, severe cognitive impairment, hemiplegia, and dysphagia, required her head of bed to be elevated at least 30 degrees during and after enteral feedings to prevent aspiration. Despite these requirements, a CNA was observed lowering the resident to a flat position while the feeding pump was running, contrary to the care plan and facility policy. Video evidence showed that after the resident was laid flat, white fluid began coming from her mouth, consistent with possible aspiration of tube feeding formula. The LPN present did not immediately intervene to stop the feeding pump or reposition the resident, and there was a significant delay in providing suctioning. The LPN was also observed searching for equipment and not demonstrating a sense of urgency, and the feeding pump remained on for an extended period after the resident showed signs of aspiration. The LPN did not perform a thorough assessment, such as checking vital signs or lung sounds, and post-mortem care was initiated before a registered nurse pronounced death, as required by protocol. Interviews with staff revealed inconsistent and incorrect knowledge regarding the care of residents with enteral feedings, including who is authorized to operate feeding pumps and the importance of head-of-bed elevation. Some CNAs believed it was acceptable to lay residents flat or to pause the pump themselves, while others were unaware of the risk of aspiration. The facility's own policies required head-of-bed elevation and nurse oversight of feeding pumps, but these were not followed, resulting in actual harm to the resident.
Failure to Timely Report Resident Elopement Incidents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by regulation. Specifically, the facility did not report two separate elopement incidents involving a resident with significant cognitive impairment and multiple medical conditions, including end stage renal disease, dementia, and altered mental status. The first incident occurred when the resident was found outside the facility attempting to cross the street, and the second incident involved the resident being found across the street at an apartment complex. In both cases, there was no evidence that the incidents were reported to the State Survey Agency (SSA) as required. The resident in question had a documented history of confusion, memory loss, and impaired decision-making, and was assessed as being at risk for elopement. Despite this, there were no elopement assessments completed prior to the second incident, and the care plan interventions for elopement risk were not implemented until after the resident was found outside the facility. Staff interviews revealed inconsistencies in the recognition and reporting of the elopement events, with some staff unaware of previous incidents and others unsure of the reporting requirements. There were also no incident reports or witness statements completed for either elopement event. Facility policy required immediate reporting of suspected abuse, neglect, or elopement to the appropriate authorities, but review of records and staff interviews confirmed that these procedures were not followed. The events were not documented in the facility's reporting system, and the required notifications to the SSA were not made. The lack of timely reporting and investigation of these incidents constituted a failure to comply with regulatory requirements for the protection of residents.
Failure to Care Plan for Medication Refusals
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed a resident's repeated refusal of medications over an extended period. The resident, a male with a history of traumatic subdural hemorrhage, generalized idiopathic epilepsy, and other significant medical conditions, was admitted with multiple medication orders, including anticonvulsants, antidepressants, supplements, and antihypertensives. Despite frequent and documented refusals of these medications, the care plan did not include measurable objectives, timetables, or interventions specifically addressing the resident's medication refusal behavior. Record reviews showed that the resident consistently refused various prescribed medications, as documented in the electronic Medication Administration Record (eMAR) by multiple medication technicians and nurses. These refusals were noted for critical medications such as seizure medications, blood pressure medications, and supplements, with refusals occurring on numerous dates across several months. Interviews with staff, including medication technicians, nurses, the MDS Coordinator, and administrative personnel, confirmed that the resident's refusals were well known among staff and were communicated during staff meetings and to the medical provider. However, these refusals were not incorporated into the resident's care plan, and there was no evidence of individualized interventions or strategies to address the refusals. Facility policy required that comprehensive, person-centered care plans include measurable objectives and timetables to meet residents' needs, and that care plans be updated as new information became available. Staff interviews revealed an understanding that medication refusals should be care planned, as this would inform all caregivers of the issue and guide appropriate interventions. Despite this, the care plan for the resident did not reflect the ongoing medication refusals, resulting in a lack of documented strategies or goals to address the resident's non-compliance with medication administration.
Failure to Administer and Document Prescribed Medications and Enteral Feedings
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident with multiple complex medical conditions, including a history of traumatic subdural hemorrhage, epilepsy, and seizure disorders. Record review revealed that the resident did not receive several prescribed medications and enteral feedings on multiple occasions, as evidenced by blank spaces in the electronic Medication Administration Record (eMAR) for various dates. The medications not administered included a nicotine patch, folic acid, a multivitamin, vitamin B1, docusate sodium, levetiracetam, Tylenol, and enteral nutrition, all of which were ordered by the physician and documented in the resident's care plan and medical orders. Interviews with nursing staff, including charge nurses and the DON, confirmed that blank entries in the eMAR indicated that medications were not administered, constituting medication errors and poor quality of care. Staff acknowledged that it was their responsibility to ensure proper documentation and administration of medications, and that failure to do so could result in the resident not receiving necessary treatment. The administrator and nurse managers also stated that they were ultimately responsible for ensuring accurate documentation and that if it was not documented, it was not done. The facility's own policies on medication administration and refusal of treatment require that medications be administered as prescribed and that any refusals or omissions be thoroughly documented, including the reason for refusal, the resident's response, and notification of the physician. However, there was no documentation in the medical record to indicate that the resident refused the medications or that the physician was notified of missed doses. The lack of documentation and administration of prescribed medications and enteral feedings represents a failure to meet the pharmaceutical needs of the resident as required by facility policy and regulatory standards.
Failure to Document Medication Refusals and Notify Providers
Penalty
Summary
The facility failed to ensure accurate documentation of medication refusals and appropriate notification to medical providers and responsible parties for one resident. Over a period spanning from May to June, the electronic Medication Administration Record (eMAR) showed multiple instances where the resident refused various prescribed medications, including seizure medications, antihypertensives, vitamins, and supplements. Despite these refusals being recorded in the eMAR, there was no corresponding documentation in the resident's progress notes indicating that the physician (MD), nurse practitioner (NP), or responsible party (RP) had been notified of these refusals. Interviews with nursing staff, including LVNs and the ADON, confirmed that the facility's expectation was for nurses to document medication refusals in the progress notes and to notify the MD, NP, and RP each time a refusal occurred. Staff acknowledged that failure to document these actions constituted a gap in care and could result in a lack of follow-up or intervention. The interviews also revealed that the responsibility for documentation rested with both the charge nurse and the nurse administering the medication, and that the absence of documentation implied that the required notifications likely did not occur. Further, the facility was unable to provide a policy on documentation when requested. The administrator and DON both stated that proper documentation and notification were essential for ongoing patient care and that medication refusals should be treated as a change in condition, requiring thorough documentation and communication. The lack of documentation in this case meant that the medical team was not fully informed about the extent of the resident's medication refusals, particularly for critical medications such as those for seizure control.
Failure to Provide Tracheostomy Care Due to Lack of Orders and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required tracheostomy care. Upon admission, the resident had a documented tracheostomy, as indicated in the hospital discharge instructions, which specified the need for portable trach suctioning and identified the presence of a Shiley trach. However, the facility's admission records, care plans, and assessments did not reflect the presence of a tracheostomy, and no orders for tracheostomy care or suctioning were entered into the system. As a result, there was no evidence that tracheostomy care was provided during the resident's stay. Interviews with nursing staff and facility leadership revealed inconsistent practices and a lack of recall regarding the resident's tracheostomy status. Staff members described standard procedures for admitting residents with tracheostomies, including the expectation to enter standing or provider-verified orders for tracheostomy care and suctioning. Despite these protocols, none of the staff interviewed could confirm that such orders were entered or that care was provided for this resident. The facility's documentation and in-service records also did not show any recent training or education on tracheostomy care for staff. The resident's medical history included hypertensive heart disease, chronic kidney disease, and thyroid cancer, and he was alert and oriented at the time of admission. The lack of tracheostomy care orders and documentation of care, despite clear hospital discharge instructions, resulted in the resident not receiving necessary respiratory care during his stay. This deficiency was identified through record review and staff interviews, which confirmed the absence of required orders and care.
Failure to Provide Timely and Consistent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice to promote healing and prevent new pressure ulcers for one resident with significant risk factors and existing wounds. The resident, an elderly female with severe cognitive impairment, bowel incontinence, immobility, and multiple comorbidities, was admitted with a stage 2 sacral pressure ulcer, deep tissue injury to the left heel, and a surgical abdominal wound. Despite being identified as high risk for pressure ulcers, the facility did not ensure timely wound care interventions, as there was a delay between the physician's referral to wound care and the first visit by the wound care specialist. Documentation showed that wound treatments were not consistently administered, and there were gaps in the administration of prescribed nutritional supplements and vitamins intended to support wound healing. The sacral wound deteriorated from a stage 2 to a stage 4 ulcer, eventually measuring 7 cm by 13 cm by 3 cm, and required debridement for necrotic tissue. The facility did not implement new interventions when the wound failed to heal, and there was no evidence of regular wound assessment or timely notification to the provider when the wound worsened. Additionally, the care plan lacked specific details about the location of wounds, and interventions such as turning and repositioning were not consistently documented or performed. Staff interviews revealed confusion and inconsistency in documentation practices, with some staff unable to verify if repositioning was done as required, and others reporting that documentation systems did not allow for accurate recording of care provided. Observations and interviews indicated that the resident was often found in the same position for extended periods, and there was a persistent odor in the room, suggesting inadequate hygiene and wound care. Family members reported not being informed about the wound's condition and had to intervene to secure emergency medical attention when the resident became lethargic and the wound appeared significantly worsened. The resident was subsequently hospitalized with fever and sepsis, and the hospital assessment found the sacral wound to be larger and more severe than previously documented by the facility. Similar failures in repositioning and documentation were observed for two other residents, indicating a pattern of deficient care.
Failure to Provide Scheduled Showers and Bed Baths for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, for three residents who were dependent on staff for these tasks. Scheduled showers and bed baths were not consistently provided according to the facility's own shower schedule and care plans. For example, one resident who was dependent for all ADLs and had significant medical needs, including pressure ulcers and cognitive impairment, did not receive scheduled bed baths on multiple occasions, with documentation showing only two bed baths in a 30-day period. Another resident, who was cognitively intact but physically impaired and required maximal assistance for bathing and dressing, did not receive scheduled showers for extended periods, including gaps of up to 12 days without a shower. This resident reported to surveyors that she had not refused showers, had filed grievances, and sometimes experienced body odor due to missed showers. She also expressed concerns about staff not returning to assist her after promising to do so, particularly when two staff members were needed for safe transfers. A third resident, who was totally dependent on staff for bathing due to impaired balance and limited mobility, also missed multiple scheduled showers and filed grievances about not receiving them. Interviews with staff revealed inconsistencies in documentation, issues with access to the electronic charting system, and a lack of clarity regarding responsibility for entering shower records. Observations confirmed that shower documentation was incomplete and not consistently entered into the electronic system, with paper records left unfiled. The facility's own ADL policy required daily documentation and regular monitoring, which was not followed.
Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
A deficiency occurred when a resident with a Foley catheter and ostomy was not provided with appropriate catheter care to prevent urinary tract infections. Observations revealed that the resident's Foley catheter bag was found lying on the bed near his left calf and later hanging on the floor, rather than being secured below the bladder as required. The resident reported that the catheter was not strapped down, causing discomfort and embarrassment, and that the bag would become heavy and painful. Staff interviews confirmed that the catheter bag was not consistently positioned correctly and that the resident had not been educated on the risks associated with improper placement of the catheter bag. The resident, a 59-year-old male with diagnoses including malignant neoplasm of the rectosigmoid junction, infection of a continent stoma, chronic kidney disease, and an artificial urinary opening, was dependent for all functional abilities and cognitively intact. The care plan included maintaining the functionality and dignity of the ostomy, but did not address the Foley catheter. Staff acknowledged that the catheter bag should be kept below the bladder to prevent infection and that the bag should be secured to the resident's thigh, but these practices were not consistently followed. Facility policy also required the catheter to be secured and the drainage bag to be positioned lower than the bladder at all times.
Failure to Timely Update Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, specifically omitting information regarding newly ordered tube feedings. The resident, a male with a history of muscle weakness, traumatic brain injury, and gastrostomy status, was admitted with severe cognitive impairment as indicated by a BIMS score of 3. Physician orders documented the initiation of Isosource tube feeding, and clinical notes confirmed administration began as ordered. However, review of the resident's care plan on multiple dates showed no inclusion of tube feeding information until several days after the order was implemented, despite the resident actively receiving tube feedings during this period. Interviews with facility staff revealed that the process for updating care plans involved multiple roles, including the MDS nurse, ADON, and Patient Care Coordinator, but there was a lack of timely interdisciplinary communication and action to ensure the care plan reflected the resident's current needs. The Director of Nursing acknowledged that the care plan should be updated promptly to guide staff in providing appropriate care and confirmed the delay in updating the care plan to include tube feeding instructions. Facility policy requires ongoing assessment and timely revision of care plans as resident conditions change, which was not followed in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure the accurate administration of medications for two residents, leading to significant medication errors. One resident, a male with a history of prostate cancer, urethral stricture, and a stage 4 pressure ulcer, was administered morphine more frequently than prescribed. The resident was supposed to receive morphine ER 30 mg every 12 hours and morphine IR 15 mg every 6 hours as needed. However, the resident received morphine IR 15 mg more frequently than ordered, leading to excessive sedation and the need for Narcan administration to counteract the overdose. Another resident, who was immunocompromised due to acute myeloblastic leukemia and neutropenia, missed four doses of Posaconazole, an antifungal medication, because it was unavailable. Despite the resident's representative offering the medication, the facility declined to administer it, insisting on using their pharmacy. The resident was readmitted to the hospital with a fever, indicating a potential infection due to the missed doses. Interviews with staff revealed a lack of communication and adherence to medication administration protocols. Staff members were aware of the discrepancies and missing medications but failed to take appropriate actions, such as notifying the physician or ensuring timely delivery from the pharmacy. The facility's policies on medication administration and communication with the pharmacy were not effectively implemented, contributing to the deficiencies observed.
Removal Plan
- An Emergency QAPI was held to review the findings of the citations and the community's present practices and processes.
- The DON and administrator will have a collaborative effort with respect to monitoring medications upon admission, and daily thereafter for established residents regarding missing or unavailable medications.
- Ongoing monitoring by DON or designee, to review medications for compliance.
- 100% audit of all residents receiving both immediate release and extended-release medications will have MAR to Cart audits to ensure appropriate medications are being given.
- Initiation of the Medication Availability Log, in which each Nurse/Med-Aide validates that they have all available medications for Administration each shift.
- Report will be reviewed in clinical stand up for morning and afternoon shift to review communication with physician on medications not available.
- A New order report will be printed by the DON/Nurse Managers, this will be cross-referenced to validate physical availability of new medications in the community.
- Pharmacy Delivery Sheets will be reviewed by DON/Nurse Managers for medications that were delivered.
- The Clinical Smart Board, which is within our EMR, displays missed medications, will be reviewed by the DON/Nurse managers, in clinical stand up for both morning and afternoon shift to review medications given, missed medications.
- The DON/Nurse Management will communicate with pharmacy regarding medications not available and get estimated time of arrival or need to STAT medications.
- The DON/Nurse Management will communicate with physician and/or medical director on medications missed or not available on patients that issues were identified.
- The DON/Nurse Management will communicate all with physician and/or medical director on medication errors.
- The DON/Nurse Management will notify the Administrator on all issues identified with pharmacy and medication delivery, availability and missed doses as well as medication errors.
- In addition to education on utilizing the Pyxis and Pharmacy Service in-services, a review of current policies and procedures were completed with the QAPI team determining that the current policy was sufficient and new protocols were put into place to achieve compliance.
Inaccurate Documentation of Nebulizer Treatments
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to potential delays or omissions in necessary interventions. For one resident, a nurse documented pre- and post-nebulizer oxygen saturation levels, despite not administering the nebulizer treatment. Additionally, the nurse did not document the resident's vital signs at the time they were obtained, which is against the facility's documentation policy. The Director of Nursing (DON) confirmed that vital signs should be documented at the time they are obtained or, if documented later, the time should be noted. Another resident received a nebulizer treatment, but the nurse documented a post-nebulizer oxygen saturation level without actually checking the resident's oxygen saturation. The nurse admitted to estimating the oxygen saturation based on observation rather than using a pulse oximeter, which is required to ensure the treatment's effectiveness. The DON confirmed that the nurse should have used the pulse oximeter to monitor pre- and post-nebulizer treatment oxygen saturation levels. The facility's policy on charting and documentation emphasizes the importance of complete and accurate medical records to facilitate communication among the interdisciplinary team regarding the resident's condition and response to care. The failure to adhere to this policy could result in inaccurate data, potentially leading to delays or omissions in necessary interventions for the residents involved.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to Enhanced Barrier Precautions (EBP) for residents requiring such measures. Specifically, staff members entered rooms of residents on EBP without wearing the required personal protective equipment (PPE) such as gowns, which is necessary during high-contact care activities. This was observed in the case of Resident #44, who required total assistance for transfers and had a G-tube, necessitating EBP. A staff member, CNA C, assisted in transferring the resident without donning a gown and failed to perform hand hygiene after removing gloves. In another instance, two staff members provided incontinent care to Resident #92, who also required EBP due to having a G-tube and pressure ulcers, without wearing gowns. Despite the presence of an EBP sign on the door, the staff members only wore masks and gloves. One of the staff members, CNA B, acknowledged forgetting to wear a gown, while CNA C expressed frustration with the precautionary measures. Interviews with facility staff, including the Charge Nurse, Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Infection Control Preventionist, confirmed that the staff should have been wearing gowns during these high-contact activities. The Enhanced Barrier Precautions sign clearly indicated the requirement for gowns and gloves during specific care activities to prevent the transmission of multidrug-resistant organisms (MDROs).
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, CR #2 and Resident #10, as per professional standards and their care plans. CR #2, a female resident with COPD and other respiratory conditions, had an order for continuous oxygen at 3L/min. However, documentation showed she was on room air multiple times, and her oxygen saturation levels were not consistently monitored or reported to the physician when they fell below the target level. Notably, an oxygen saturation of 84% was recorded without notifying the physician, and there was a lack of continuous supervision during nebulizer treatments. Interviews with staff revealed discrepancies in documentation and a lack of adherence to protocols. LVN T admitted to errors in documenting CR #2's oxygen status and nebulizer treatments, and the DON confirmed that the physician should have been notified of the low oxygen saturation. The ADON and DON highlighted the importance of monitoring changes in condition, especially for residents with respiratory issues, but these protocols were not followed, leading to a failure in addressing CR #2's needs. For Resident #10, the facility also failed to properly assess and document oxygen saturation levels following nebulizer treatments. LVN Z did not use a pulse oximeter post-treatment and inaccurately documented a 98% oxygen saturation based on observation rather than measurement. This lack of proper monitoring and documentation could have compromised the resident's care, as the effectiveness of the treatment was not accurately assessed.
Failure to Follow Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow the treatment orders for a resident's left distal/medial foot as prescribed by the Nurse Practitioner. The resident, who has a history of type 2 diabetes mellitus, local infection of the skin, and pressure-induced deep tissue damage of the left heel, was supposed to have betadine applied to the affected area and covered with a kerlix bandage daily. However, on one occasion, the Wound Care Nurse applied betadine but failed to cover the wound with the bandage as ordered. The resident, who is severely cognitively impaired and dependent on staff for personal care, was observed sitting in a wheelchair with a pressure-relieving boot on her left leg. Despite the resident expressing satisfaction with her care, the failure to follow the treatment order was noted during an observation of wound care. The Wound Care Nurse acknowledged not following the doctor's order, which could potentially lead to damage to the arterial wound if the resident moved with the wound exposed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a violation of the resident's rights to reasonable accommodation of their needs and preferences. The deficiency was identified during an observation and interview process, where it was noted that the call light for a resident was hung on the bed headboard, out of the resident's reach. This was confirmed during two separate observations on the same day. The resident, who was bedfast and had a history of general muscle weakness and cerebral infarction, was unable to answer questions, indicating a potential communication barrier. Interviews with the unit manager and the facility administrator revealed that it was the responsibility of the nurses and CNAs to ensure that call lights were within reach of residents. The unit manager acknowledged that the call light might have been left on the headboard after care was provided, and confirmed that the resident would not be able to call for assistance due to the call light's inaccessibility. The facility's policy on answering call lights and the call system emphasized the importance of ensuring that residents have a means to call for assistance, which was not adhered to in this instance.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of soiled sheets and a strong urine odor in the resident's room. The resident, who required assistance with activities of daily living due to conditions such as muscle weakness, dementia, and epilepsy, was found sitting in his wheelchair in a room with a noticeable urine smell and stained sheets. The resident reported waiting for staff to change his bed linens for about 30 minutes. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) was unaware of the soiled sheets and acknowledged that they should have been changed immediately. The Certified Nursing Assistant (CNA) responsible for changing the linens admitted to being distracted by another resident's request and leaving the room without completing the task. The CNA acknowledged that the resident's needs were not met and that other staff could have assisted. The facility's policies emphasize treating residents with dignity and ensuring consistent care, which was not adhered to in this instance.
Pest Control Deficiency in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in resident rooms. On December 4, 2024, a live brown roach was observed in a resident's room between the laundry basket and bedside nightstand. The resident reported seeing roaches frequently, especially when the lights were off, and expressed fear that the roaches might crawl into her bed. This indicates that the pest control measures in place were insufficient to keep the resident rooms free from pests. The facility's pest control vendor had visited and treated the facility for roaches on two occasions in November 2024. Despite these treatments, the problem persisted, particularly in the 500 and 1000 halls, as acknowledged by the Administrator. The Administrator noted that the issue worsened during rainy conditions and emphasized that all staff were responsible for reporting insect sightings. The facility's policy, revised in May 2008, stated that an ongoing pest control program should ensure the building is free of insects and rodents, which was not effectively implemented in this case.
Failure to Provide Consistent ADL Assistance
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. This deficiency was observed in a resident who was physically impaired and dependent on staff for assistance with ADLs, including bathing and clothing changes. The resident, who had severe cognitive impairment and multiple medical conditions, was supposed to receive showers on specific days during the 2:00 p.m. - 10:00 p.m. shift. However, records indicated that the resident did not consistently receive these showers, leading to body odors and complaints from the resident's family. Interviews with staff revealed that the 2:00 p.m. - 10:00 p.m. shift often failed to provide the scheduled showers and clothing changes for the resident. A CNA from the 6:00 a.m. - 2:00 p.m. shift reported taking the initiative to give the resident showers due to concerns about the lack of care from the later shift. The resident's family also expressed concerns about the resident not receiving showers and being found in the same gown for multiple days, which sometimes resulted in odors. Despite these issues, the facility's documentation did not consistently reflect the missed showers or clothing changes. The facility's administrator acknowledged that the resident's family had complained about missed showers and clothing changes. However, the administrator claimed that the showers were given the next day after a missed appointment. The lack of proper documentation and accountability for the 2:00 p.m. - 10:00 p.m. shift contributed to the ongoing issue, as the resident's hygiene needs were not consistently met, leading to grievances from the family and potential risks for the resident.
Failure to Secure Catheter Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections. The resident, an elderly female with severe cognitive impairment and a history of cerebral infarction, acute kidney failure, and urinary retention, was observed without a catheter stabilizer in place. This oversight was noted during a care session where the CNA attempted to reapply the stabilizer but found the adhesive was not sticking. The CNA acknowledged the importance of the stabilizer in preventing the catheter from being pulled out or displaced. Interviews with facility staff, including an LVN and the DON, revealed a lack of consistent monitoring and communication regarding the resident's catheter care. The LVN admitted to relying on CNAs to inform him if the catheter stabilizer was not secured, while the DON emphasized that it was the nursing staff's responsibility to ensure the catheter was anchored properly. The facility's policy on catheter care, which aims to prevent catheter-associated urinary tract infections, specifies that catheters should be secured with a leg strap to reduce friction and movement at the insertion site.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA B during the provision of incontinence care to Resident #1. CNA B did not perform hand hygiene after removing soiled gloves and before applying new gloves, which led to cross-contamination. While wearing soiled gloves, CNA B touched various items in the resident's environment, including the bedside drawer, barrier cream container, clean dress, brief, and sheets. This lapse in protocol could potentially place residents at risk for the spread of infection. Resident #1, a female with severe cognitive impairment, was dependent on an indwelling catheter and required substantial assistance with personal hygiene. Her care plan highlighted the risk of complications such as recurrent urinary tract infections. During the observation, CNA/Activity also failed to adhere to proper infection control practices by double-gloving, which is against the facility's policy. Interviews with the staff, including the Administrator and DON, confirmed that these actions were not in line with the facility's infection control policies, which emphasize the importance of hand hygiene as the primary means to prevent the spread of infections.
Inadequate Supervision and Improper Transfer Technique
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices during the transfer of a resident, leading to a deficiency in accident prevention. The resident, who was severely cognitively impaired and totally dependent on two-person physical assistance for transfers, was inappropriately transferred by a CNA. The CNA lifted the resident under the arms and placed him into a wheelchair without using a gait belt, despite the presence of another staff member in the room who could have assisted. This improper transfer technique was captured on video and reported by the resident's family member. The resident's care plan indicated the need for extensive to total assistance with activities of daily living, including transfers, and the facility's policy required the use of a gait belt for all assisted transfers. Interviews with staff confirmed that they were trained to use gait belts to reduce the risk of injury during transfers. The Director of Nursing acknowledged the improper transfer and confirmed that staff were not trained to perform such transfers. The CNA involved was terminated following the incident.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident, leading to a deficiency in care. The resident, a female with dementia, insomnia, and constipation, was admitted to the facility and required substantial assistance with activities of daily living, including toileting and personal hygiene. The resident was always incontinent of both bowel and bladder, as noted in her care plan, which aimed to maintain her dignity by keeping her clean, dry, and odor-free. However, during an observation, a CNA did not properly clean the resident during incontinent care, failing to spread the labia and clean the urinary meatus, which is a necessary step to prevent infections. The CNA, who worked on a PRN basis, admitted to not performing the task correctly due to nervousness, acknowledging that this failure placed the resident at risk for infections. The Director of Nursing stated that staff were expected to provide complete and proper incontinent care and that training and competency checks were provided upon hire and quarterly. Despite this, the facility did not provide a policy on incontinent care upon exit, and the Incontinent Care Skills Checklist indicated the proper procedure was not followed.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during incontinence care for a resident. The CNA did not perform hand hygiene before entering the resident's room or before donning clean gloves. During the care process, the CNA removed soiled gloves without washing or sanitizing her hands and donned new gloves, continuing to provide care and touch clean items with potentially contaminated hands. This lapse in proper hand hygiene could lead to cross-contamination and the spread of infection. The resident involved was an elderly female with dementia, insomnia, and constipation, requiring substantial assistance with activities of daily living, including toileting and personal hygiene. The resident was always incontinent, necessitating careful and hygienic care. The CNA, who worked PRN and had not completed competency checks or in-service training on infection control at this facility, acknowledged the risk of cross-contamination due to improper hand hygiene. The facility's policies on infection control and hand hygiene were not adhered to, as evidenced by the CNA's actions and the lack of documented training.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of roaches, gnats, and flies in various areas, including the kitchen, dining area, and resident rooms. Observations on multiple occasions revealed gnats flying in the kitchen, flies in the dining area, and roaches climbing on the kitchen walls. Interviews with the Dietary Manager and aides confirmed the ongoing issue with pests, despite regular visits from a local pest control company. The Dietary Manager acknowledged the presence of gnats and was informed by staff about roaches, although she had not personally seen them. The facility's pest control policy, dated 2008, stated that the building should be kept free of insects and rodents, yet the maintenance log recorded multiple instances of roach sightings in resident rooms over several months. During an interview with the local pest control contractor, it was noted that a fly light bulb near the kitchen entrance was out, which could have contributed to the fly and gnat problem. The contractor suggested changes in handling fruit deliveries to reduce pest attraction. Despite these efforts, the presence of pests persisted, as evidenced by the state investigator's observation of roaches during the interview. The facility's failure to effectively control pests placed residents at risk of infection and food-borne illnesses, as acknowledged by the Dietary Manager and Administrator.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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