The Manor At Seagoville
Inspection history, citations, penalties and survey trends for this long-term care facility in Seagoville, Texas.
- Location
- 2416 Elizabeth Ln, Seagoville, Texas 75159
- CMS Provider Number
- 675418
- Inspections on file
- 41
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at The Manor At Seagoville during CMS and state inspections, most recent first.
Mechanical/Hoyer lifts on two resident halls were observed unlocked and unsecured, parked in room doorways while residents maneuvered their wheelchairs around them. An RN, an LVN, and a CNA each stated that mechanical lifts should be locked when not in use and stored away from high-traffic resident areas, noting that failure to lock them could result in injuries such as broken limbs or serious harm requiring hospitalization. The facility’s Mechanical Lift Protocol states that all lifts are to be returned to their assigned lift station when not in use, but this was not followed.
A resident with moderate cognitive impairment and multiple medical diagnoses was receiving ordered G-tube feedings of FEEDING 2 CAL HN at a specified rate and duration, but surveyors observed that the feeding bag and tubing in use were not labeled with date, time of initiation, or resident information. The LVN caring for the resident acknowledged that facility policy requires labeling of enteral feedings to ensure timely replacement and prevent contamination and admitted the setup should have been labeled. An RN confirmed that feedings must be labeled before administration and that all feedings are to be discarded after 24 hours, and the DON stated her expectation that the administering nurse label and date the feeding and that each assigned nurse verify proper labeling, consistent with facility policy requiring documentation of date, time, amount, method, and related details for tube feedings.
A resident receiving IV Cefepime via a midline catheter did not have the IV antibiotic bag labeled with the start date/time or nurse initials, and the IV tubing was not dated, contrary to facility IV therapy policy requiring all IV tubing to be labeled with date, time, and initials and changed at specified intervals. The resident’s active care plan lacked focus areas or interventions related to IV therapy. The LVN who administered the medication acknowledged forgetting to date and initial the IV medication and tubing despite prior in-servicing, and the DON confirmed that nurses were expected to label IV medications and tubing during every antibiotic administration, noting the risk of infection and medication error.
A resident with heart failure and moderate cognitive impairment, receiving O2 at 2 L/min via nasal cannula, was found using oxygen tubing dated several weeks earlier and an empty humidifier, despite an active order for weekly tubing and humidifier changes. Nursing staff gave conflicting information about whether changes were to occur on Wednesday or Saturday nights, while the DON stated policy required weekly changes and checks as part of routine assessment. Although staff reported being in-serviced on infection control and oxygen tubing care, the ordered schedule for changing the resident’s oxygen equipment was not followed.
A resident with complex medical needs experienced a misappropriation of property when approximately 23 tablets of Hydrocodone and the associated narcotic log went missing from the medication cart. Despite staff shift counts and negative drug tests for all involved, the medication and log were never recovered, and the facility could not determine how the diversion occurred. The resident did not miss any doses, but the event represented a failure to protect the resident from drug diversion.
A facility failed to maintain accurate records and perform proper shift-to-shift counts for controlled substances, resulting in the loss of approximately 23 tablets of Hydrocodone and the corresponding narcotic log for a resident with complex medical needs. Staff were unable to account for the missing medication, and required documentation was not completed or was missing, despite policies mandating these procedures.
A resident with complex medical needs did not have required medications and treatments documented by an RN during a double shift, resulting in missing entries in the MARs and TARs. The lack of documentation included essential care such as tracheostomy care, wound care, and medication administration, with staff interviews revealing unawareness of the issue and attributing it to possible EMR system problems.
A resident with severe cognitive impairment and a recent catheterization experienced bleeding and was sent to the hospital. Afterward, the resident's family reported an allegation of sexual abuse by a staff member to facility staff. The administrator was notified but did not immediately report the allegation to law enforcement as required, instead initiating an internal investigation and delaying police notification for two days.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital due to a significant change in condition, but the responsible party was not notified at the time of transfer as required by facility policy. The omission was discovered after a grievance was filed by the family member, and the LVN involved reported forgetting to notify due to being busy.
A resident with severe cognitive impairment and mobility needs did not have a care plan that included specific interventions for bed positioning to prevent falls, despite a recent fall and changes in her condition. Staff did not consistently follow or update the care plan, and the interdisciplinary team did not revise it to reflect the resident's current needs, resulting in a deficiency in care planning.
A treatment cart containing prescribed topical ointments and sterile supplies was found unlocked and unattended while an LVN was in a resident's room. The LVN admitted forgetting to lock the cart, and the Administrator confirmed that facility policy requires carts to be locked when not in direct view of staff.
The facility failed to provide necessary nail care for three residents, resulting in long, unclean fingernails. Despite requiring assistance, the residents did not receive proper grooming, leading to increased risks of infection and loss of dignity. Staff interviews revealed a lack of awareness and responsibility for nail care duties, contrary to the facility's policy.
The facility's kitchen failed to meet food service safety standards, with observations of uncovered, unlabeled, and expired food items in the walk-in freezer and refrigerator. Interviews with staff confirmed the responsibility of all kitchen personnel to ensure proper food labeling and storage, which was not adhered to, posing a risk of food-borne illness.
A facility failed to update a resident's care plan to include management of a dialysis AV fistula in the left forearm. The resident, who was cognitively intact and had conditions such as hypertension and end-stage renal disease, had physician orders for regular checks of the dialysis site. However, these were not included in the care plan, potentially affecting the resident's care. Interviews with staff confirmed the oversight.
A resident with a history of stroke, diabetes, and heart failure was observed using oxygen without a physician's order, contrary to facility policy. The resident's care plan and medical records lacked documentation for oxygen therapy, and the DON confirmed that orders are necessary unless in emergencies. This oversight led to a deficiency in providing appropriate respiratory care.
A facility failed to label and date medications properly, as observed with open bottles of valproic acid and levetiracetam on a medication cart without open dates. An LVN administered these medications without checking expiration dates, despite acknowledging the importance of dating for effectiveness. Interviews with the ADON and DON confirmed the policy of dating medications upon opening and removing them after 28 days.
A CNA failed to follow enhanced barrier precautions during incontinence care for a resident with multiple health issues, including blindness and end-stage renal disease. The CNA did not wear a gown while providing care, despite the resident being on enhanced barrier precautions due to her medical condition. Interviews with facility staff confirmed the expectation for PPE use during high-contact care activities, as outlined in the facility's infection control policy.
A resident in a long-term care facility experienced discomfort after a caregiver applied Icy Hot to their bottom instead of the prescribed barrier cream during incontinence care. Despite the resident's complaint of burning, the caregiver did not remove the cream. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, was later assessed and cleaned by another nurse. The Director of Nursing confirmed that the caregiver was not qualified to apply Icy Hot, as there was no order for its use at the time.
A caregiver in an LTC facility applied Icy Hot to a resident without a physician's order and without being qualified, leading to a burning sensation for the resident. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, kept the Icy Hot for personal use, but it was mistakenly used during incontinence care. The facility's policy required only licensed individuals to administer medications, which was not followed.
A resident in an LTC facility experienced a burning sensation after a caregiver mistakenly applied Icy Hot cream instead of a barrier cream during incontinence care. The resident, who was cognitively intact and had the cream stored in his drawer for shoulder pain, did not have an order for the cream. The facility failed to store the cream properly, as required by State and Federal laws, and the caregiver did not verify the cream before application, contrary to the facility's medication administration policy.
Unlocked Mechanical Lifts Left in Resident Hallways
Penalty
Summary
Surveyors identified a deficiency in maintaining an environment free from accident hazards on the 200 and 300 halls, where mechanical/Hoyer lifts were left unlocked and unsecured when not in use. On the 300 hall, an unlocked and unsecured mechanical lift was observed parked in the doorway of a resident room, with residents maneuvering their wheelchairs around the lift. A similar observation was made on the 200 hall, where another unlocked and unsecured mechanical lift was parked in the doorway of a resident room, again with residents maneuvering their wheelchairs around it. These lifts were not stored at their assigned lift stations as outlined in the facility’s Mechanical Lift Protocol, which states that all lifts will be returned to their assigned lift station to charge when not in use. During interviews, RN A stated that Hoyer/mechanical lifts should be stored away from high-traffic areas where residents could access them and get hurt, and confirmed he had been in-serviced on mechanical lifts, including storage. LVN C stated that mechanical lifts should always be locked in common areas such as hallways when not in use and that Hoyer lifts are stored at the end of the hall away from residents; she stated that failure to lock the lifts could cause accidents, including broken arms or legs. CNA D stated that mechanical lifts must always be locked and the red button activated to ensure there are no moving parts, and that a resident might attempt to support themselves and sustain serious injuries requiring hospitalization. The DON stated that her expectation was that all mechanical lifts were to be locked when not in use and that all staff had been educated and trained in proper usage and safety of mechanical lifts.
Unlabeled Enteral Feeding Setup for G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an enteral feeding setup was properly labeled and dated in accordance with professional standards and facility policy for one resident receiving G-tube feedings. The resident was an adult female with moderate cognitive impairment (BIMS score 12) and diagnoses including hypertension, aphasia, and respiratory care needs. Her MDS and care plan documented that she required tube feeding with FEEDING 2 CAL HN at 40 ml/hour via feeding tube, to run from 9:00 a.m. to 7:00 a.m. for a total volume of 880 ml over 22 hours, with the head of bed elevated and residuals checked per protocol. Active physician orders matched these parameters. During an observation at 10:22 a.m., surveyors noted that the resident’s enteral feeding bag and tubing connected to the G-tube were unlabeled, with no indication of the date, time of initiation, or resident information. In interviews, the LVN assigned to the resident confirmed she was responsible for the resident and stated that facility policy required labeling of enteral feedings to ensure timely replacement and prevent contamination, acknowledging that the feeding setup should have been labeled and attributing initiation of the feeding to the night shift. An RN stated that enteral feedings should be labeled before administration and explained that unlabeled feedings could result in administration of expired feeding, noting that all feedings should be discarded after 24 hours and that he had been in-serviced on G-tube feeding administration. The DON stated her expectation that the nurse administering the feeding would label and date the feeding before administration and that each nurse assigned to the resident should check during their assessment to ensure the feeding was properly labeled, noting the risk of administering the wrong feeding and not knowing how long the feeding had been infused. Facility policy on administration of formula via feeding tube required documentation of date and time of feeding, amount, method and route of delivery, patient reactions and tolerance, and recording of formulas, water amounts, and medications, further underscoring that the observed unlabeled feeding setup did not comply with established procedures.
Failure to Label IV Antibiotic and Tubing per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the administration and labeling of IV antibiotic therapy for Resident #1. The resident was a female with moderate cognitive impairment (BIMS score 12), admitted with diagnoses including hypertension and respiratory care, and her MDS reflected IV medications and IV access. Physician orders dated 03/20/2026 directed Cefepime HCl 2 gm/100 ml to be given intravenously every 8 hours for 14 days. On 04/01/2026 at 10:20 a.m., observation showed the resident receiving Cefepime via a midline catheter, but the IV antibiotic bag was not labeled with the date and time it was initiated or the initials of the nurse who administered it. The IV tubing in use was also not dated, despite facility policy requiring all IV tubing to be labeled with date, time, and initials and changed every 96 hours or sooner if contamination or system compromise was suspected. Record review on 04/01/2026 at 10:10 a.m. showed that the resident’s active care plan did not include any focus areas or interventions related to IV therapy or the identified failure. During an interview at 10:24 a.m., LVN C, who was the resident’s nurse and had administered the IV antibiotic, acknowledged she had forgotten to date and initial the medication and to date the IV tubing, and stated she had previously been in-serviced on IV medication administration requirements, including dating and initialing at the time of administration. In a separate interview at 4:26 p.m., the DON confirmed that nurses were expected to initial and date IV medications and IV tubing during every antibiotic administration and stated that the risk to the resident included infection and not knowing when the medication was started, which could lead to a medication error. The facility’s written Intravenous Therapy policy, implemented 12/1/2025, required all IV tubing to be labeled with date, time, and initials, which was not followed in this instance.
Failure to Follow Oxygen Tubing and Humidifier Change Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and physician orders for a resident receiving oxygen therapy. A female resident with heart failure, moderate cognitive impairment (BIMS score of 12), and an active care plan for oxygen therapy was observed on 2 L/min oxygen via nasal cannula. Record review showed an active physician order for oxygen tubing and humidifier changes every Wednesday night shift. However, on observation, the oxygen tubing in use was dated several weeks earlier and the humidifier bottle attached to the oxygen setup was empty. The resident’s care plan included monitoring for signs and symptoms of respiratory distress and obtaining SpO2 as needed for shortness of breath, and there was a facility policy for safe oxygen administration and documentation, but the ordered schedule for changing equipment was not followed. Staff interviews revealed inconsistent understanding of when oxygen tubing and humidifiers were to be changed. One RN stated the resident was on continuous oxygen and that nurses were responsible for checking and changing oxygen tubing, indicating tubing and humidifiers were changed every Wednesday night. An LVN, however, stated that oxygen tubing and humidifiers were supposed to be changed on the Saturday night shift and that she usually checked tubing to ensure it was dated. The DON stated her expectation was that the assigned nurse should check oxygen tubing and nebulizer masks as part of the overall assessment and that facility policy was to change oxygen tubing and humidifiers weekly and when dirty or contaminated. Staff, including the RN, LVN, and DON, all reported that nurses had been in-serviced on infection control and oxygen tubing care, yet the resident’s tubing and humidifier were not changed per the active order.
Failure to Prevent Drug Diversion of Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the diversion of approximately 23 tablets of Hydrocodone, a controlled narcotic medication. The resident, who had diagnoses including end stage renal disease requiring dialysis, dyspnea, hyperkalemia, fluid overload, and pain, was prescribed Hydrocodone-Acetaminophen for pain management. The medication was documented as missing from the medication cart, along with the corresponding narcotic log, during a routine medication administration. Multiple staff statements indicated that the medication and log were present during previous shift counts, but were later discovered missing, and no staff could account for their disappearance. The facility's investigation included reviewing staff statements, drug testing all staff who had access to the medication cart, and auditing medication carts and logs. Staff involved in the medication management process denied diverting the medication and all tested negative for controlled substances. The missing medication and narcotic log were never recovered, and the facility was unable to determine how the medication was diverted or who was responsible. The pharmacy confirmed delivery of the medication, and the resident did not miss any doses, as another blister pack was available and used for administration. The resident was out of the facility on leave when the diversion was discovered and reported that he had not missed any doses of his pain medication. Staff interviews and record reviews confirmed that the resident's pain management was not interrupted, and he expressed feeling safe and having no concerns about medication administration. The facility's policies required strict accounting and shift-to-shift counting of controlled substances, but the failure to prevent the diversion of the resident's medication and the associated narcotic log constituted a failure to protect the resident from misappropriation of property.
Failure to Maintain Accurate Controlled Substance Records Resulting in Missing Medication
Penalty
Summary
The facility failed to maintain an established system of records for the receipt and disposition of all controlled drugs, resulting in the inability to accurately reconcile controlled substances for one hall and one resident who had orders for controlled medications. Specifically, the facility did not ensure that employees with access to controlled medications properly counted the inventory, and approximately 23 tablets of Hydrocodone, along with the corresponding medication card and narcotic log, were missing from the medication cart. Staff statements indicated that the medication card was present at the end of one shift but was missing at the start of another, and no staff member could account for its disappearance. The required narcotic count sheets and logs were not completed or were missing, and the facility was unable to determine how the medication and log went missing. The resident involved was a male with end stage renal disease requiring dialysis, as well as other significant medical conditions including dyspnea, hyperkalemia, fluid overload, and pain related to a recent surgical procedure. He was prescribed Hydrocodone-Acetaminophen for pain management, with orders for administration every four hours as needed. Documentation showed that the resident had not missed any doses of his pain medication, as another card of the same medication was available and used during the period in question. However, the facility's failure to maintain accurate records and perform proper shift-to-shift narcotic counts led to the loss of both the medication and the narcotic log, and staff were unable to provide an explanation for the discrepancy. Interviews and record reviews revealed that staff who had access to the medication cart denied diverting the medication and tested negative for controlled substances. The facility's policies required verification and documentation of controlled medication receipt, shift-to-shift counts, and immediate reporting of discrepancies, but these procedures were not followed in this instance. The missing medication and log were never located, and the facility was unable to identify the individual responsible for the loss or diversion of the controlled substance.
Failure to Document Medication and Treatment Administration in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a registered nurse (RN) did not document the administration of physician-ordered medications and treatments for a resident during her assigned double shift. Review of the resident's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the specified date showed missing initials and lack of documentation for multiple required treatments, including tracheostomy care, wound care, nebulizer treatments, aspiration precautions, and vital sign monitoring. There was also no progress note or other nursing documentation indicating that the care and medications were provided on that day. The resident involved was a male with severe cognitive impairment and total dependence for activities of daily living. His medical history included hypertension, neurogenic bladder, diabetes, Parkinson's disease, respiratory failure, anoxic brain damage, and a history of tracheostomy and G-tube feeding. He required frequent and complex care interventions, such as suctioning, oxygen therapy, skin care, and regular monitoring for signs of aspiration and infection. Despite these needs, the required documentation to confirm that these interventions were performed was absent for the identified shift. Interviews with facility staff revealed that the RN believed she had provided the care but attributed the lack of documentation to possible technical issues with the new electronic medical record (EMR) system. Other staff, including the Director of Nursing (DON) and the Weekend Supervisor, were unaware of the missing documentation until after the fact. The facility's own policies required that all care, medications, and treatments be documented in the resident's medical record, including the date, time, and details of the care provided. The absence of this documentation meant there was no verifiable record that the resident received the necessary care and treatments as ordered.
Failure to Timely Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident was reported immediately to local law enforcement, as required by state law. The incident involved a male resident with severe cognitive impairment and a diagnosis of vascular dementia, depression, and insomnia. The resident was admitted for short-term care and had a physician's order for a Foley catheter. On the day of the incident, the resident experienced bleeding from the urethra during catheter removal, which was documented by nursing staff and resulted in the resident being sent to the hospital. After the resident was hospitalized, a family member reported to facility staff that the resident had alleged sexual abuse by a staff member. The administrator was notified of the allegation after midnight, and the information was relayed to the Director of Nursing and the corporate office. However, the administrator did not immediately notify local law enforcement, as required. Instead, the administrator initiated an internal investigation and reported the incident to the state, but delayed contacting the police until two days after the initial allegation was made. Interviews with facility staff and family members confirmed the timeline of events and the delay in reporting to law enforcement. The administrator stated that she did not contact the police initially because the resident was not present at the facility and she did not find evidence to substantiate the allegation. The facility's own abuse protocol required immediate reporting to authorities within two hours for incidents involving reasonable suspicion of serious bodily injury or abuse, which was not followed in this case.
Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to immediately notify a resident's responsible party when there was a significant change in the resident's condition that resulted in a hospital transfer. Specifically, a resident with severe cognitive impairment, a history of cerebral infarction, depression, and anxiety disorder, was assessed by an LVN who found the resident with thick secretions, low oxygen saturation, labored breathing, and unresponsiveness. The resident was subsequently sent to the emergency room. Despite facility policy requiring notification of the resident's representative in such situations, the responsible party was not informed of the transfer at the time it occurred. The omission was discovered when the resident's family member filed a grievance after learning about the hospital transfer. The responsible party was listed in the resident's records as having all responsibilities, and the facility's policy clearly stated that notification was required for significant changes in condition or hospital transfers. The LVN involved later stated that the failure to notify was due to being busy and forgetting to make the call.
Failure to Update and Implement Comprehensive Care Plan for Resident at Fall Risk
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented to meet all of a resident's needs, specifically for a female resident with severe cognitive impairment, dysphagia, and high blood pressure. The care plan did not include clear interventions regarding the lowering of the bed to prevent falls, despite the resident's recent fall and her need for assistance with transfers and bed mobility. Observations showed that the resident's bed was not in the lowest position as required, and staff interviews revealed inconsistencies in following and updating the care plan based on the resident's current abilities and risks. Record reviews indicated that the care plan was not revised after a significant change in the resident's condition, and the interdisciplinary team had not updated the plan to reflect the resident's individual needs for bed positioning, especially at night. Staff were relying on the care plan for guidance, but it did not accurately reflect the resident's current care requirements. The facility's policy required ongoing assessment and timely updates to care plans, but this was not followed, resulting in a deficiency related to the development and implementation of a complete care plan.
Unlocked Treatment Cart Left Unattended
Penalty
Summary
A deficiency was identified when treatment cart #1 was observed to be unlocked and unattended while a licensed vocational nurse (LVN) was inside a resident's room. The cart contained prescribed topical ointments and sterile supplies, and its drawers could be easily opened. This observation was made during a survey, and the LVN confirmed in an interview that she was aware the cart should have been locked but stated she forgot to do so. She acknowledged that leaving the cart unlocked could allow residents access to ointments, which could potentially be ingested. Further interview with the Administrator confirmed that treatment carts are required to be locked when not in the direct sight of staff, in accordance with facility policy. The Administrator also recognized the risk of residents accessing treatment creams and supplies if the cart is left unlocked. Review of the facility's medication administration policy, revised in April 2019, supported the requirement that medication carts must remain closed and locked when out of sight of the medication nurse or aide.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in three residents who had long, unclean fingernails, which were not trimmed or cleaned by the staff. Resident #34, with severe cognitive impairment and requiring moderate assistance with personal hygiene, had nails approximately 1.0 centimeter in length with black areas underneath. Despite her request for assistance, the staff did not offer nail care during her stay. Resident #11, with moderately impaired cognition and requiring moderate assistance for personal hygiene, also had long nails with a dark red and brown substance underneath. She expressed a desire for her nails to be trimmed but could not recall when they were last attended to. Similarly, Resident #64, with a history of stroke and right-sided weakness, had nails that were not properly trimmed, with pointed, jagged edges and a dark substance underneath. She was unable to remember when her nails were last trimmed. Interviews with staff revealed a lack of awareness and responsibility regarding nail care. CNAs were identified as responsible for cleaning and trimming nails, but there was a disconnect in communication and execution of these duties. The facility's policy on nail care, which aims to prevent infection and maintain hygiene, was not adhered to, leading to increased risks of infection and loss of dignity for the residents.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the walk-in freezer were not covered, labeled, or dated with expiration dates. An unopened bag of cauliflower florets and a bag of diced yellow squash lacked expiration dates, while a bag of diced chicken was left uncovered. Additionally, the walk-in refrigerator contained tomato sauce in a covered container that was past its shelf life of seven days and should have been discarded. Interviews with the Dietary Manager and another staff member confirmed that all kitchen staff, including dietary aides and cooks, were responsible for ensuring food items were dated, labeled, and covered according to facility guidelines. The Dietary Manager acknowledged that the failure to properly manage food storage could lead to food-borne illnesses. The facility's policy on food storage was reviewed and found to lack specific guidance on the type of date required on food products. The Food and Drug Administration Food Code was also referenced, highlighting the need for proper food labeling and storage to prevent contamination.
Failure to Update Care Plan for Dialysis Access
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #32, which included measurable objectives and time frames to address the resident's mental and psychosocial needs. Specifically, the care plan did not include the management of the resident's dialysis access in the left forearm fistula. This oversight was identified during a review of the resident's comprehensive care plan, which was last updated on 09/19/22, and did not list the dialysis AV fistula as a care area or problem. Resident #32, a cognitively intact male with a BIMS score of 14, was admitted with diagnoses including hypertension, renal insufficiency, end-stage renal disease, and hyperkalemia. The physician's orders required regular checks of the dialysis site for thrill, bleeding, and signs of infection, with any abnormalities to be reported to the MD. However, these requirements were not reflected in the resident's care plan. Interviews with the MDS coordinator and the DON confirmed the care plan should have been updated to include the dialysis AV fistula, and the failure to do so could affect the resident's care.
Failure to Obtain Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received appropriate care consistent with professional standards. Specifically, the facility did not have a physician's order for the use of oxygen for a resident who was observed using oxygen via a nasal cannula. The resident, who was cognitively intact, had a history of cerebral infarction, type 2 diabetes mellitus, and unspecified diastolic heart failure. Despite these conditions, there was no documentation in the resident's care plan or medical records indicating a physician's order for oxygen therapy. Observations and interviews revealed that the resident was administered oxygen without a physician's order, which is against the facility's policy. A nurse placed the oxygen concentrator and nasal cannula in the resident's room without administering it, yet the resident was observed using it. The Director of Nursing confirmed that a physician's order is required for oxygen administration unless in an emergency situation. The facility's policies on physician orders and oxygen administration were not followed, leading to the deficiency.
Failure to Label and Date Medications Properly
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with accepted professional principles, specifically by not including the open date on medication bottles for a resident. During an observation, it was noted that the 300 Hall medication cart contained open bottles of valproic acid and levetiracetam oral solutions without the required open date. This oversight was confirmed by LVN E, who administered these medications to the resident without checking for expiration dates. The LVN acknowledged the importance of dating medications to ensure they are not used beyond their effective period. Interviews with the ADON and DON further highlighted the facility's policy that liquid medications should be dated upon opening and removed after 28 days to maintain their effectiveness. The ADON mentioned conducting random checks of medication carts, while the pharmacist performed monthly checks and provided staff education. The facility's policy on medication labeling and storage emphasized contacting the dispensing pharmacy for instructions on handling outdated or improperly labeled medications.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to enhanced barrier precautions during incontinence care for a resident. The resident, a severely cognitively impaired female with multiple health issues including end-stage renal disease and blindness, was on enhanced barrier precautions due to her medical condition. During an observation, the CNA was seen providing care without wearing a gown, despite the presence of feces in the room after the resident had removed her ostomy bag. Interviews with the CNA, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the facility's expectations were for staff to follow enhanced barrier precaution guidelines, which include the use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. The CNA acknowledged forgetting to wear a gown and recognized the risk of infection to the resident and others. The facility's policy on enhanced barrier precautions, revised in March 2024, outlines the necessity of PPE during specific care activities to prevent the transmission of multidrug-resistant organisms.
Resident's Rights and Dignity Compromised by Improper Application of Topical Cream
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, which compromised the resident's quality of life. A caregiver applied Icy Hot, a topical pain reliever, to a resident's bottom instead of the prescribed barrier cream during incontinence care. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, complained that the Icy Hot burned. Despite the resident's complaint, the caregiver did not remove the cream, leading to discomfort for the resident. The incident was reported to the Director of Nursing (DON), who confirmed that the caregiver was not qualified to apply Icy Hot, as there was no order for its use at the time. The caregiver claimed that the resident asked to be "greased up" and agreed to the application of Icy Hot, which was kept in the resident's drawer for personal use. The DON acknowledged that the caregiver should have verified the substance before application and noted the risk of an adverse reaction. The resident was later assessed and cleaned by another nurse, but the initial failure to address the resident's complaint promptly resulted in a temporary decrease in the resident's quality of life.
Improper Administration of Topical Medication by Unqualified Caregiver
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Icy Hot, a topical over-the-counter pain reliever. A caregiver applied Icy Hot to a resident without a physician's order and without being qualified to do so. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, reported that during incontinence care, Icy Hot was applied to his bottom instead of the prescribed barrier cream, causing a burning sensation. The resident kept the Icy Hot in his drawer for personal use on his shoulder, and it was mistakenly used by the caregiver. The Director of Nursing (DON) confirmed that the resident did not have an order for Icy Hot at the time of the incident, and the caregiver was not qualified to apply it. The caregiver admitted to applying the Icy Hot after the resident requested to be "greased up" and confirmed its use with the resident. The facility's policy stated that only licensed or permitted individuals could administer medications, which was not adhered to in this case. The incident was reported to the DON, and the Icy Hot was subsequently removed from the resident's room.
Improper Storage and Application of Medication
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was identified during a review of a resident's room where an over-the-counter topical cream, Icy Hot, was improperly stored. The resident, a cognitively intact male with diagnoses including hypertension and end-stage renal disease, had the Icy Hot cream in his drawer, which was used by his wife for shoulder pain. The resident reported that during incontinence care, a caregiver mistakenly applied the Icy Hot cream to his bottom instead of the prescribed barrier cream, causing a burning sensation. The Director of Nursing (DON) confirmed that the resident did not have an order for Icy Hot at the time of the incident, and the cream should have been stored on the medication cart if there was an order. The caregiver involved stated that she applied the Icy Hot after the resident requested to be "greased up" and did not verify the cream before application. The facility's policy on administering medication requires that medication carts be kept closed and locked when out of sight, and no medications should be kept on top of the cart. The incident highlighted a failure to adhere to these storage and administration protocols, potentially placing residents at risk of medication misuse and diversion.
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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