The Woodlands Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in The Woodlands, Texas.
- Location
- 4650 S Panther Creek Drive, The Woodlands, Texas 77381
- CMS Provider Number
- 455876
- Inspections on file
- 36
- Latest survey
- April 25, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at The Woodlands Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with significant mobility and continence issues, but intact cognition, reported inconsistent housekeeping and inadequate bathroom cleaning, which surveyors corroborated by observing debris, dirt, and dried hand sanitizer along a hall, as well as bathrooms with urine odor, dark urine left in toilets, toothpaste splatter on mirrors, black or brownish-red rings in toilet bowls, and fecal splashes on commodes and assisted toilet chairs. Staff interviews showed CNAs believed housekeeping was responsible for bathroom cleaning, while housekeeping and EVS described daily cleaning expectations and detailed procedures that were not reflected in observed conditions, despite a facility policy requiring regular cleaning and disinfection of toilets and maintenance of floors free from accumulations of dirt.
A resident with MS, major depressive disorder, and quadriplegia, who required total assistance for bathing and extensive assistance for personal hygiene per MDS and care plan, was taken to the shower by a CNA and another aide. After being placed in the shower chair and having his clothing and covering removed, the CNA left him alone in the shower room, stating she was giving him privacy and would return. The resident later documented that he was left naked and cold without a towel or hot water, unable to reach the faucet or bathe himself, with his catheter bag left in his lap causing urine to run onto his leg, and that he tried to call for help by yelling and banging the shower head on the wall. Facility leadership interviews showed the Administrator was unaware of the complaint, the DON acknowledged the resident would need assistance in the shower, and an LVN described that staff should normally provide showers with periodic checks, while facility policy required necessary ADL services for residents unable to perform self-care.
A resident with brain cancer, cerebral edema, seizure disorder, and a history of falls was admitted with elevated BP and multiple ordered meds, some of which were documented as unavailable, and there was no documented MD/NP confirmation of her medication regimen. In the early morning, she sustained an unwitnessed fall and developed a forehead hematoma; nursing notes show she was found on the floor and later transferred to the hospital, but her family reports they were not called, discovered the injury only after arriving on-site, and found her call light out of reach. The family also reported the RN was off the unit in his car, appeared unaware of the extent of the head injury, stated he was overwhelmed by his caseload, and initially resisted calling 911 despite the family’s request. The NP later confirmed she had not been notified of the fall or medication issues, and the administrator stated nurses are expected to assess, perform neuro checks, and immediately notify the physician and family after a fall, supporting the deficiency for failure to immediately inform the physician and family and to appropriately respond to the resident’s change in condition.
A resident with brain cancer, cerebral edema, left hemiparesis, seizure disorder, HTN, DM, CAD, and a history of multiple falls was admitted with a complex medication regimen, but key medications were documented as unavailable, and there was no clear evidence of timely medication reconciliation with the MD/NP. That evening, the resident had elevated BP and exhibited erratic behavior and frequent care needs, yet this behavior and any interventions were not documented. During the night, the resident fell while apparently unable to access a call light or phone, was found on the floor by a CNA, and was lifted back to bed with delayed RN response and without a clearly documented pre-lift assessment, neuro checks, or immediate vital signs, despite a subsequent large forehead hematoma and significantly elevated BPs recorded by EMS. The family learned of the fall directly from the resident rather than staff, reported that the resident said she had not received her medications, and described staff who were unaware of the head swelling and admitted feeling overwhelmed, while the MD/NP later confirmed they had not been notified of the admission medication review or the fall with head injury.
Surveyors found that two dining room emergency exits were not maintained in a safe and functional condition. One exit had its exterior sidewalk cluttered with items such as cleaning equipment, furniture, a grill, crates, and a large trash bin, obstructing the exit path. The other exit had its only accessible ramp blocked by a large pallet of medical supply boxes stacked on the sidewalk, leaving minimal clearance at the curb edge. Central supply staff reported that multiple pallets were delivered to the back of the building after a storage shed was condemned and acknowledged that supplies should not be left outside and that the blocked ramp was a problem. The Maintenance Director confirmed that the delivery company placed pallets on the walkway and that the area was obstructed, and the Administrator confirmed these doors were designated exits and that the ramp was primarily used for deliveries. The report noted that this practice could place residents at risk of falls, injuries, and confusion during evacuations.
A facility failed to report a suspicious, unwitnessed head laceration requiring hospitalization for a resident with dementia and a history of falls. Despite the injury being unexplained and meeting criteria for an injury of unknown source, the administrator did not submit the required report to the State Survey Agency, resulting in a deficiency in abuse and incident reporting procedures.
A resident with a chronic, necrotic BKA stump and a history of non-compliance with wound care was found with maggots and roaches in the wound after being outside, despite orders for regular wound care and dressing. Staff interviews revealed inconsistent wound coverage and monitoring, and the infestation was not detected until advanced, leading to hospital transfer and above-knee amputation. The facility did not ensure wound care was provided and monitored according to professional standards.
Two nurses failed to follow proper hand hygiene and glove-changing procedures during suprapubic catheter care for two residents, including not sanitizing hands or changing gloves before applying clean dressings. Both staff members acknowledged forgetting these steps, and the DON confirmed expectations for hand hygiene were not met, as outlined in facility policy.
A resident with multiple chronic conditions missed a scheduled dose of Testosterone Cypionate after nursing staff failed to reorder the medication in accordance with facility policy, resulting in a one-week delay before the medication was administered. Staff interviews and record reviews confirmed the lapse in the medication reordering process and a lack of documentation regarding the timing of the reorder.
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Undated food items were found in dry storage, the refrigerator, and the freezer, with some items improperly sealed and showing signs of freezer burn. The Dietary Supervisor was unaware of expiration dates, and the facility's policy on food storage was not being followed, potentially placing residents at risk of foodborne illness.
A medication aide failed to perform hand hygiene between administering medications to three residents, leading to a potential risk of cross-contamination. The residents involved had various health conditions, including Alzheimer's, diabetes, and respiratory issues. Despite having completed a competency evaluation, the aide admitted to forgetting to sanitize hands due to nervousness, highlighting a lapse in the facility's infection control practices.
A resident with complex medical conditions was administered Midodrine, a blood pressure medication, against physician orders, which specified holding the medication if systolic blood pressure (SBP) exceeded 130. Despite this, the medication was given on multiple occasions when the resident's SBP was above the threshold. Interviews with the involved RNs revealed awareness of the error, and the facility's policy required adherence to physician orders, but the monitoring process failed to prevent the mistake.
A facility failed to securely store medications, as a resident's Tramadol blister pack had torn seals, risking drug integrity and infection control. The nurse responsible did not routinely check packaging integrity, and the DON confirmed the importance of intact seals to prevent drug diversion and infection issues.
Failure to Maintain Clean and Sanitary Resident Rooms and Hallways
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment, including sanitary conditions in resident rooms and common areas. On Hall A of the long-term care unit, surveyors observed debris, dirt, food particles, and black sticky dried hand sanitizer beneath three dispensers along the hallway floor. These substances appeared adhered to the floor but could be partially lifted with slight pressure, indicating they had been present for some time and not adequately cleaned. One resident, a man with quadriplegia, neuromuscular bladder dysfunction, CHF, full fecal incontinence, colostomy status, multiple sclerosis, hypertension, and hemiplegia, was identified as affected. His care plan documented an ADL self-care performance deficit and noted that he refused to use the sink in his room, instead using a public sink near the dining room, and that he had limited mobility due to multiple sclerosis. Despite having normal cognitive function (BIMS score of 15), he reported that housekeeping was inconsistent, stating that one housekeeper mopped without sweeping first and that his bathroom had not been thoroughly cleaned, resulting in a black ring in the toilet from prolonged unclean conditions. In his bathroom, surveyors observed balled-up dirty gloves left on the counter, toothpaste splatter on the mirror, and a strong urine odor from a toilet containing dark yellow urine, even though the resident did not use the toilet due to a catheter and relied on staff to empty his handheld urinal. Another room on Hall A was also found to be unclean. In that bathroom, the mirror had visible water and toothpaste splashes, the toilet bowl had a black ring, and there were dark brown fecal splashes on the commode and assisted toilet chair. A CNA stated that CNAs were responsible for bed-making and patient care while housekeeping cleaned bathrooms, and reported that she flushed the toilet after emptying the resident’s urinal, later attributing any failure to flush to a malfunctioning handle; however, the toilet flushed fully when tested, and a brownish-red ring remained in the bowl. A housekeeper described a cleaning process that included sweeping before mopping, disinfecting surfaces, and thoroughly scrubbing toilets, but when shown a picture of the toilet bowl, she acknowledged the ring could be from mildew or buildup and that it could have been present for a while. The DON stated she had not received complaints from the resident and expected housekeeping to keep things clean, and the EVS supervisor stated that housekeeping was to clean rooms daily with a focus on sanitation, consistent with the facility’s general housekeeping policy requiring the facility to be kept free from accumulations of dirt and to clean and disinfect toilets, including the bowl and base.
Resident Left Unattended, Unclothed, and Unable to Self-Bathe in Shower
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a manner that promoted maintenance of a resident’s quality of life and to treat the resident with respect and dignity. A resident with multiple sclerosis, major depressive disorder, and quadriplegia was admitted with significant ADL self-care performance deficits and required total assistance of two staff for tub bath/shower three times weekly, as well as extensive assistance of one person for personal hygiene and oral care. His quarterly MDS showed a BIMS score of 15, indicating no cognitive impairment, and documented that he was dependent on others for bathing, including washing, rinsing, and drying, and had functional limitations in range of motion in both lower extremities and one upper extremity. On the day of the incident, a CNA reported that she and another CNA assisted the resident into a shower chair and took him to the shower room, which was initially occupied. After the other resident left, the CNA and the resident entered the shower room. The CNA stated she got him situated in the shower, placed the call light within reach, and asked if he needed help; the resident told her he needed help with his legs and feet. The CNA said she told him she would give him privacy and return, then left to use the restroom and came back about five minutes later. She stated that when she returned, the resident was upset, had not started showering himself, and that she believed he was safe in the shower without supervision and not a fall risk, and that she thought he could wash himself. In contrast, the resident’s contemporaneous note on his phone described being left naked and cold in the shower, unable to do anything to help himself, with no towel or covering, and no hot water. He documented that his catheter bag was left in his lap, causing him to urinate on his leg, and that he used the shower head to bang on the wall and yelled as loudly as he could but the CNA was gone. He reported this to the former ADON. The Administrator later stated he was not aware of a complaint regarding this incident. The DON, who had only recently started working at the facility, stated that whether residents could be in the shower independently would depend on their capabilities, and acknowledged that this resident would need assistance in the shower. An LVN stated that for this resident, staff would normally provide the shower as he wanted it, including closing the curtain for privacy if requested and checking on him every 3–5 minutes. The facility’s ADL policy required that residents unable to carry out ADLs receive necessary services for bathing, grooming, and personal hygiene based on their comprehensive assessment and needs.
Failure to Notify Physician and Family and Appropriately Respond After Unwitnessed Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify the physician and family, and to appropriately respond, after a resident experienced an unwitnessed fall with a head injury shortly after admission. The resident was an older female admitted on 1/16/26 with multiple serious diagnoses, including grade 4 glioblastoma multiforme with chemo and brain resection, cerebral edema, left hemiparesis after cerebral infarct, CAD with two stents, diabetes mellitus, hypertension, seizure disorder, arthritis, and a history of multiple falls at home. On admission, her blood pressure was documented at 164/100 by LVN A, but no interventions were put in place. Several of her ordered medications, including dexamethasone and cyclosporine eye drops, were documented as "Medication Unavailable" the evening of admission. LVN A stated she called the MD or NP to verify medications but did not leave a voicemail and there was no documentation of this contact in the nursing notes, while the NP later reported she had not been notified about the resident or any medication review. In the early morning hours of 1/17/26, RN A documented that around 1:20 a.m. the resident was found on the floor, brought back to bed, and had vital signs assessed, with no swelling or bruising initially noted; 30 minutes later, a small swelling was observed on the left side of her forehead. A later nursing note at 4:18 a.m. documented a change of condition, stating the resident had fallen and had a bruise on her left forehead and was transferred to the hospital. However, the resident’s family member reported that no one from the facility called her about the fall or the head injury; she learned of the incident directly from the resident and arrived at the facility around 1:40 a.m. to find the resident with a significantly swollen knot on the left side of her head. The family member also stated the resident’s call light had been behind the bed and out of reach, and that the resident’s phone was not within reach when the fall occurred. The family member reported that when she arrived, RN A was not on the unit and had to be located outside in his car by CNA A. She stated that RN A appeared surprised by the extent of the resident’s head swelling and told her he was overwhelmed by the number of residents he was responsible for, and that the resident was not the only one who had fallen. The family member demanded that the resident be sent to the hospital, but reported that RN A initially refused to call 911, stating he needed permission from the DON and instead sought authorization to use a regular ambulance service. EMS records show multiple elevated blood pressure readings during transport. The NP later confirmed she had not received any call, message, or text from LVN A regarding medication review or from RN A regarding the fall with head injury, and only learned of the situation days later from a voicemail from the DON. The administrator stated that the expectation is that after a fall, especially an unwitnessed fall, the nurse should assess the resident, perform neuro checks and vital signs before moving the resident, and immediately notify the family and physician, and that if a family requests hospital transfer, the resident should be sent out. The resident was hospitalized with an admitting diagnosis of fall, initial encounter, from [DATE] to 01/25/26. The facility’s own Promoting/Maintaining Resident Dignity policy states that all staff must protect and promote resident rights, treat residents with respect and dignity, report and document information regarding resident preferences, and speak respectfully to residents. The family member’s email to the facility and corporate office described the environment as dangerous, alleged that an inexperienced nurse admitted to sleep deprivation and inability to manage his caseload, and complained that support staff prioritized their phones over patient safety. She specifically questioned why she was not called immediately after the fall, why a resident with a seizure history was left without a call button, and why a nurse who reported being sleep-deprived was caring for her mother. The NP’s and MD’s interviews, combined with the lack of documentation of physician notification and the family member’s account of not being notified, support the finding that the facility failed to immediately inform the physician and the family of the resident’s fall with head injury and did not follow its own expectations for post-fall assessment and communication.
Failure to Provide Timely Post-Fall Assessment, Medication Management, and Safe Call-Light Access
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and services, including fall prevention, timely response, and appropriate post-fall assessment, for a newly admitted resident with complex medical conditions. The resident, an older female admitted with grade 4 glioblastoma multiforme status post brain resection, cerebral edema, left hemiparesis after cerebral infarct, CAD with stents, DM, HTN, seizure disorder, arthritis, and a history of multiple falls at home, arrived on 1/16/26. Hospital discharge paperwork listed numerous medications, including antihypertensives, seizure medication, steroids, and others. Facility records showed some medications (dexamethasone and cyclosporine) documented as “medication unavailable” on the evening of admission, and there was no documented medication reconciliation or confirmation with the MD/NP regarding all admission medications. The NP later reported she had not been contacted about the admission or medication review, and the pharmacy reported medications ordered on 1/16/26 were never picked up and were returned to stock after 14 days, with no record of transfer to a closer store. On the evening and night of admission, the resident was documented as having elevated blood pressure (164/100) at 7:57 p.m., with no documented interventions. Interviews indicated the resident exhibited erratic behavior, spoke incoherently, and required frequent assistance, but this behavior was not documented in the nursing notes. CNA and family interviews described that the resident did not consistently use the call light and often called out verbally for help. CNA A reported that the roommate complained about the resident’s noise and requested a room change, and that she asked the resident to quiet down but did not report this behavior to the charge nurse. CNA A stated she assisted the resident to the restroom and back to bed, placing the call light, water, and phone within reach, while the family member later reported the call light was behind the bed and the phone unplugged and out of reach. The family member stated the resident told her she had not received all of her medications that night. In the early morning hours of 1/17/26, the resident experienced a fall. Nursing notes by RN A at 1:20 a.m. documented that the resident was found on the floor, brought back to bed, and had vital signs assessed, with no swelling or bruising initially noted and a small swelling on the left forehead noted 30 minutes later. A later note at 4:18 a.m. documented a change of condition, a fall with a bruise on the left forehead, and transfer to the hospital. However, CNA A reported that when she first found the resident on the floor and notified RN A, he delayed going to the room, stating he needed to enter information in the computer, and that when he arrived, he helped lift the resident back to bed without performing any assessment or vital signs before or immediately after the lift. CNA A stated she did not observe RN A perform neuro checks or vitals, and that the resident’s swelling was not noted until the family arrived. The family member reported receiving a distress call directly from the resident around 1:16 a.m., stating she had fallen, hit her head, and was bleeding, and that no staff had called her. Upon arrival around 1:40 a.m., the family member found CNA A at the nurses’ station on her phone, and then was escorted to the room where CNA A stated she had cleaned blood from the resident’s head and applied a cold towel but had not escalated the issue to the nurse. The family member described a large swollen knot on the resident’s left forehead and stated RN A was initially not in the building and was later found outside in his car. The family member reported that RN A appeared unaware of the head swelling, admitted being overwhelmed and responsible for many residents, and stated that residents fall frequently. The family member also stated that the resident reported not receiving her medications and that RN A said medications would arrive around 3:00 a.m., but no medications arrived by the time EMS transported the resident. Further interviews revealed inconsistencies in RN A’s account of post-fall care. RN A stated he took vital signs after putting the resident back in bed and completed neuro checks every 15 minutes, documenting them either on sticky notes or in nursing notes, but he could not clearly recall the method. He also stated he could not remember if he checked whether the resident was on anticoagulants before moving her and acknowledged he did not perform range-of-motion assessment while the resident was on the floor. The NP reported receiving no call or message about the fall or head injury, and the MD/NP had no record of being notified at the time of the incident. EMS records documented significantly elevated blood pressures during transport. The administrator later stated that the expectation for an unwitnessed fall is to perform an assessment, neuro checks, and vital signs before lifting the resident from the floor and to notify the family and physician immediately afterward, which contrasted with the actions described in staff and family interviews. The facility’s own investigation summary noted that the family member alleged verbal abuse by CNA A, including telling the resident to go to sleep because she was bothering the roommate, and alleged that the resident had not received all her medications on the night of admission. CNA A confirmed asking the resident to quiet down due to the roommate’s complaints but denied verbal abuse. The DON acknowledged that the resident’s disruptive behavior was not documented and that the LVN who received the resident should have completed a medication review with the MD or NP. The facility’s Promoting/Maintaining Resident Dignity policy required staff to treat residents with respect, pay attention to residents as individuals, and speak respectfully, but the family’s allegations and staff interviews described interactions and omissions that did not align with these expectations. Overall, the report documents failures in fall prevention measures, timely response to a resident in distress, post-fall assessment and monitoring, medication reconciliation and availability, and communication with the family and practitioner, all contributing to the cited quality of care deficiency.
Obstructed Dining Room Emergency Exits Due to Stored Supplies and Clutter
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, functional, sanitary, and comfortable environment related to two dining room emergency exits. During observation of dining room exit door #1, surveyors noted that the sidewalk area immediately outside the door was obstructed with multiple items, including a cooler on wheels, a bucket and mop, a scrubbing brush, a piece of wood furniture, a grill, two stacked crates, another mop bucket, and a large trash bin on wheels next to the ramp. These items created clutter in the designated exit area. The facility’s own Emergency Preparedness Plan identified evacuation as a prime consideration in any disaster or emergency directly affecting the facility. For dining room exit door #2, surveyors observed that the sidewalk leading to the only ramp accessible from this exit was obstructed by a large pallet of medical supply boxes. The pallet consisted of boxes stacked approximately three across and five high, with additional rows behind, leaving only about one foot of space between the pallet and the edge of the sidewalk where the curb dropped off. Central supply staff reported that medical supplies were now delivered to the back of the facility after a storage shed had been condemned about eight months earlier, and that she received multiple pallets at a time and could not bring all boxes inside in one day. She acknowledged knowing that supplies should not be left outside and recognized that the blocked ramp was a problem. The Maintenance Director confirmed that the supply company placed pallets on the walkway and agreed that the area outside dining room exit door #2 was obstructed. The Administrator confirmed that dining room exit doors #1 and #2 were designated exits, with the ramp mainly used for deliveries, and stated that if the ramp could not be used due to obstruction, residents and staff would use another exit door. The report stated that this deficient practice could place residents at risk of falls, injuries, and confusion during evacuations.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately as required. Specifically, staff did not submit a report to the State Survey Agency regarding a resident who was found on the floor with a deep 10 cm laceration to the top of his head, which required hospitalization and 15 staples. The injury was unwitnessed, and the source could not be explained by the resident, who had a history of dementia and repeated falls. Despite the severity and unexplained nature of the injury, the incident was not reported through the required channels. The resident involved was an elderly male with diagnoses including heart failure, dementia, depression, abnormal gait, and a history of falls. On the day of the incident, staff heard a loud thump and found the resident on his back with a significant head laceration and uncontrolled bleeding. The resident was unable to explain what happened, and staff could not identify any object or surface in the room that could have caused the injury. The facility's investigation included interviews, room inspection, and review of the resident's care plan and medical records, but the cause of the injury remained undetermined. Interviews with facility staff, including the administrator and DON, revealed that the injury met the criteria for an injury of unknown source, as it was unwitnessed, unexplained by the resident, and suspicious due to its extent. However, the administrator did not report the incident, believing it was not suspicious after internal review. This decision was made despite the facility's policy and state guidance requiring immediate reporting of such injuries. The failure to report the incident as required constituted a deficiency in the facility's abuse, neglect, and incident reporting procedures.
Failure to Provide Wound Care per Orders Resulting in Infestation and Amputation
Penalty
Summary
A deficiency occurred when a resident with a history of peripheral vascular disease, cardiac arrest, and a left below-knee amputation (BKA) with chronic infection did not receive treatment and care in accordance with professional standards of practice. The resident's care plan included interventions for a left BKA stump infection, antibiotic therapy, and regular wound care, with specific orders for wound cleansing, dressing, and monitoring. Despite these orders, the resident's left stump was found to be infested with maggots and roaches, and the wound was described as necrotic, hard, and covered with eschar. The infestation was discovered after the resident had been outside in the smoking area, and staff interviews revealed that the wound was often left open to air, and the resident was known to be non-compliant with keeping dressings in place and with some aspects of care. Multiple staff members, including nurses and CNAs, reported that the resident frequently refused wound care and would remove dressings, particularly when going outside to smoke. There were also indications that the wound was not always covered as ordered, especially when the resident left the building. Staff interviews indicated that the presence of maggots was not immediately identified, and there was uncertainty about when the last wound care was performed. The wound care doctor and facility staff acknowledged the resident's non-compliance and the chronic necrotic state of the wound, but the infestation was not detected until it had progressed, resulting in the need for hospital transfer and subsequent above-knee amputation. Documentation and interviews confirmed that the facility failed to ensure consistent wound care and monitoring in line with professional standards, particularly regarding wound coverage and inspection for pests. The resident's care plan and physician orders were not fully implemented, and there was a lack of timely identification and response to the wound infestation. The failure to provide appropriate treatment and care as ordered and to monitor for changes in the wound condition led to the identification of an Immediate Jeopardy situation by surveyors.
Failure to Follow Hand Hygiene and Infection Control Procedures During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding hand hygiene and glove use during suprapubic catheter care for two residents. During catheter care for one resident with a history of acute cystitis and an indwelling suprapubic catheter, an LVN applied a clean dressing without sanitizing her hands or changing gloves after cleaning the catheter site. This was observed directly and later confirmed in an interview, where the LVN acknowledged forgetting to perform hand hygiene and glove change before dressing application. In a separate incident, an RN initiated catheter care for another resident with a suprapubic catheter and flaccid hemiplegia without washing or sanitizing her hands prior to donning gloves. The RN also failed to remove gloves and perform hand hygiene throughout the procedure, including before applying a clean dressing. The RN admitted in an interview that she forgot to wash or sanitize her hands before starting care and before dressing application, recognizing the potential for infection as a result. The Director of Nursing confirmed that there was no specific procedure for suprapubic catheter care beyond routine ADL care, but stated that her expectation was for staff to perform hand hygiene before care, after removing dirty gloves, and before applying clean dressings. Facility policy also required hand hygiene before resident contact, before donning gloves, and after glove removal, emphasizing that glove use does not replace hand hygiene. These lapses in following established hand hygiene protocols were observed and acknowledged by the staff involved.
Missed Dose Due to Failure in Medication Reordering Process
Penalty
Summary
A deficiency occurred when the facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident diagnosed with multiple complex conditions, including Multiple Sclerosis, quadriplegia, and hypogonadism. The resident was prescribed Testosterone Cypionate to be administered intramuscularly every two weeks. The medication was not administered as scheduled on one occasion due to a lapse in the medication reordering process. The lapse was identified when the nurse responsible for administering the medication on the scheduled date found that no medication was available. The nurse reported that the previous dose had been the last available, and the medication had not been reordered in time. The nurse stated that he typically reordered medications when only one dose remained but did not follow up to ensure the medication was delivered before the next scheduled administration. The facility's policy required that maintenance medications be reordered before the last dose was given, specifically 3 to 4 days in advance, to prevent any lapse in therapy. Interviews with nursing staff and facility leadership revealed confusion regarding the reordering process, particularly for controlled substances, and a lack of documentation regarding when the medication was reordered. The resident missed a scheduled dose and did not receive the medication until one week later. The incident was confirmed through record review, staff interviews, and resident interview, which indicated the resident was aware of the missed dose and the delay in administration.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. During an initial tour, surveyors observed multiple food and drink items in the dry storage, refrigerator, and freezer that were not labeled with expiration dates. Specifically, undated items included cans of diced red peppers, packages of various drink mixes, and crackers in the dry storage. In the refrigerator, packages of unknown sandwich meat were found without expiration dates. In the freezer, several opened and unsealed food items, such as fish patties, catfish nuggets, turkey breakfast sausage patties, pork sausage, and beef liver, were discovered, some of which showed signs of freezer burn. The Dietary Supervisor, who had been working at the facility for a year, was interviewed and admitted to not knowing the expiration dates or the required use-by dates for the undated food items. She mentioned a policy that required food to be labeled and stored appropriately upon delivery, but it was not being followed. The facility's policy on food storage, which was reviewed, stated that all food should be stored according to state and federal guidelines, with items labeled and dated. The failures in food storage and labeling could place residents at risk of foodborne illness, as acknowledged by the Dietary Manager.
Infection Control Lapse During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medication aide (MA S) who did not perform hand hygiene between administering medications to three residents. This lapse in protocol was observed during a medication pass, where MA S administered medications to Resident #4, Resident #14, and Resident #10 without sanitizing hands between each resident. This failure to adhere to hand hygiene practices could potentially lead to cross-contamination and the spread of infections among residents. Resident #4, a female with severe cognitive impairment and multiple health conditions including Alzheimer's disease and diabetes, was one of the residents involved. She was dependent on staff for all activities of daily living (ADLs) and had specific medication orders for hypertension. Resident #14, a male with intact cognition and conditions such as diabetes and heart failure, was independent with most ADLs and had orders for cardiac medications. Resident #10, a female with moderate cognitive impairment and high risk for respiratory infections, required supervision for most ADLs and had orders for medications related to her respiratory and nutritional needs. The Director of Nursing (DON) and the Infection Preventionist (IP) acknowledged the importance of hand hygiene in preventing infection spread. The facility's policy required handwashing before and after medication administration, which MA S failed to follow. Despite having completed a competency evaluation that included hand hygiene, MA S admitted to forgetting to sanitize hands due to nervousness. The DON and IP indicated that staff are regularly monitored for compliance with infection control practices, but this incident highlighted a lapse in adherence to established protocols.
Failure to Administer Medication According to Physician's Orders
Penalty
Summary
The facility failed to administer Midodrine, a blood pressure medication, according to the physician's orders for a resident with complex medical conditions, including hypertension and atrial fibrillation. The resident was supposed to receive Midodrine only when her systolic blood pressure (SBP) was below 130. However, the medication was administered on multiple occasions when the resident's SBP was above this threshold, specifically on three separate days by two different registered nurses (RNs). The resident's care plan and physician orders clearly indicated that Midodrine should be held if the SBP exceeded 130 to prevent the risk of elevated blood pressure. Despite this, the medication was given when the SBP was recorded at 133 and 139. Interviews with the involved RNs revealed that they were aware of the physician's parameters but failed to adhere to them, resulting in the medication being administered incorrectly. Both RNs acknowledged the error and the potential risk of causing the resident's blood pressure to rise too high. The facility's policy on medication administration required licensed nurses to follow physician orders and record vital signs, holding medications if vital signs were outside prescribed parameters. The Director of Nursing (DON) and the pharmacist confirmed that the medication administration was monitored monthly, and any issues were addressed with staff. However, in this instance, the monitoring process did not prevent the medication error, and the resident's SBP was not properly managed according to the physician's instructions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by the condition of the medication blister pill card for a resident's Tramadol HCL 50mg. During an observation and interview, it was found that the protective seals on several tablets within the blister card were torn. The nurse responsible for the medication cart acknowledged that torn seals should not be taped closed or left in the pack, as this could lead to the replacement of pills with different tablets and pose an infection control risk. Despite this, the nurse admitted that she did not routinely check the integrity of the packaging during narcotic counts. The resident involved was an elderly female with a history of Alzheimer's disease, dementia, depression, anxiety, arthritis, and stroke, who required moderate assistance with daily activities and received scheduled pain medication. The facility's Director of Nursing (DON) confirmed that nurses should check blister card seals for integrity to prevent drug diversion and infection control issues. The facility's policy on medication administration emphasized the importance of preventing contamination or infection, and staff training reinforced that compromised medications should not be administered.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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