Veranda Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Harlingen, Texas.
- Location
- 4301 S Expressway 83, Harlingen, Texas 78550
- CMS Provider Number
- 455925
- Inspections on file
- 27
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Veranda Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with severe dementia and high dependence for transfers reported rib pain after being assisted with a shower, later describing that staff lifted her by her arms while she was standing. Family reported the new right-sided pain to nursing, and an NP ordered rib x‑rays, which showed rib fracture deformities and possible pneumonia. An RN received the x‑ray report but focused on the pneumonia findings and missed the documented fractures, and did not report the injury of unknown origin to facility management as required. The DON and Administrator later acknowledged that the incident, which involved a possible neglect situation, was not reported to the state agency within the required timeframe, contrary to the facility’s abuse-prevention policy requiring immediate internal reporting and timely external reporting of all allegations and injuries of unknown source.
A resident with severe dementia, osteoporosis, and dependence on staff for transfers and bathing developed rib pain after a shower, later reporting that staff had lifted her under the arms while she was standing. CNAs reported using a two-person transfer to a shower chair and denied that the resident stood or complained of pain. Over the next days, the resident continued to report right-sided pain, leading an NP to order rib x‑rays, which showed rib fractures along with possible pneumonia; however, the initial nursing and NP review focused on the pneumonia and missed the fracture findings, delaying recognition of an injury of unknown origin. The DON later identified the fractures, sought multiple clarifications from the mobile x‑ray provider due to inconsistent rib descriptions, and then notified the NP, who arranged hospital evaluation, where CT imaging confirmed subacute and chronic bilateral rib fracture deformities. Despite facility policy requiring immediate reporting of all allegations and injuries of unknown origin to the Administrator and State agencies, the DON and Administrator acknowledged that the fracture findings and associated injury of unknown origin were not reported to the State within the required 2‑hour timeframe while the facility attempted to verify the x‑ray results.
A resident with dementia, severe cognitive impairment, and dependence for transfers and bathing was care planned for two-person assist with transfers and one-person assist for showers. After being showered, the resident later reported being stood up and lifted under the arms, experiencing rib pain that was subsequently reported by the family. An NP later ordered rib x‑rays for right-sided pain; the x‑ray showed acute mildly displaced right rib fractures and pneumonia, but an RN focused only on the pneumonia findings and missed the fractures. The DON later identified the fracture findings amid conflicting rib descriptions from multiple x‑ray readings, acknowledging that nurses were expected to read and act on x‑ray reports. This resulted in a delay in recognizing and addressing the rib fractures, contrary to professional standards, the care plan, and the resident’s expressed pain.
A resident with osteomyelitis, cellulitis, a stage 4 sacral pressure ulcer, paraplegia, and a PICC line was observed receiving IV vancomycin from a bag that lacked a proper label, showing only a date and RN initials. The bag did not include the resident’s name, medication dose, frequency, or route, despite an active order for vancomycin 1 g IV every 8 hours. The RN reported he had just hung the bag, discarded the original label, and knew the bag should have been labeled with full medication information. The DON confirmed the expectation that nurses ensure IV medication containers are correctly labeled and consistent with facility policy requiring verification of the container’s label against the prescriber’s order.
A resident with Alzheimer's disease, anxiety, and a mood disorder had a bedtime alprazolam order. On one evening, an LVN documented on the MAR that the alprazolam dose was administered, but the controlled drug record and narcotic count showed it was not given because the resident was asleep. The LVN reported she signed the MAR before checking the resident, did not remove the medication from packaging, and recorded on the controlled drug record that no dose was provided, but failed to correct the MAR entry. The DON confirmed the discrepancy and that facility policy requires documenting on the electronic MAR at the time medications are actually administered.
A medication cart was found unlocked and unattended in front of the nurse's station, with an RN responsible for the cart present nearby but not securing it. The RN stated he had unlocked the cart for an auditor and was unaware it remained unlocked. The DON confirmed that staff are expected to lock medication carts when unattended, in accordance with facility policy.
The facility did not maintain an effective pest control program, as roaches were observed coming out of a floor drain in the kitchen following nearby construction. Staff reported the issue to management, and records showed regular fumigation, but the pest problem persisted despite these efforts.
Two residents did not have comprehensive, person-centered care plans that addressed their identified needs. One resident with severe cognitive impairment and physical limitations was not care planned for required feeding assistance, and the care plan incorrectly listed a feeding tube. Another resident with nicotine dependence and COPD was not care planned for smoking, despite being on the facility's smoking list and self-reporting as a smoker. Staff interviews revealed confusion and lack of communication regarding both residents' care needs.
A resident receiving IV therapy for cellulitis was found to have a peripheral IV dressing on her right hand that was not labeled with the date and initials, as required by facility policy and professional standards. While the left wrist IV dressing was properly labeled, the right hand dressing was not, and staff interviews confirmed the omission. Facility policies and competency checklists require all IV dressings to be labeled to ensure proper monitoring and timely changes.
A resident with multiple chronic conditions and intact cognition experienced misappropriation of funds when a former ABOM accessed the resident's bank account and withdrew money without consent on multiple occasions. The unauthorized transactions went undetected by the facility until the resident noticed missing funds and reported the issue, leading to a police investigation and the staff member's admission of theft.
Two residents with behavioral health needs did not receive ordered psychiatric evaluations and treatment after incidents involving aggression and psychosocial concerns. Despite physician orders and care plan interventions, there was no documentation of psychiatric consultations or follow-up, as the responsible social worker failed to carry out the referrals.
A resident with dementia and recent cataract surgery did not receive prescribed prednisolone eye drops to the left eye at the ordered frequency, due to discrepancies between the physician's prescription and the facility's medication orders. Nursing staff and the DON reported confusion over the correct dosage and frequency, and the resident was described as resistant to providing post-visit orders, leading to the medication being administered incorrectly.
A facility failed to maintain accurate and complete medical records for a resident's DNR status. Despite the resident's clear communication and documentation of her DNR wishes, the required OOH-DNR form was missing from her medical record. Staff interviews revealed confusion and lack of responsibility in handling DNR forms, leading to the oversight.
The facility failed to maintain an infection prevention and control program, leading to deficiencies such as improper disinfection of equipment, failure to wear appropriate PPE, and incorrect PICC line dressing changes. These actions could lead to cross-contamination and infections.
A female resident with dementia and mobility issues, identified as high risk for elopement, exited the facility unnoticed and was found near a highway. The investigation revealed that she exited through a door in hall 300, despite staff attempts to redirect her. The Environmental Manager noted that the door alarm was not very loud, and landscapers working nearby might have inadvertently allowed her to leave.
The facility failed to ensure a resident had access to a call light within reach, despite the resident's need for assistance due to hemiplegia and hemiparesis. Staff interviews confirmed the importance of accessible call lights, and the facility's policy was not followed, leading to the deficiency.
Failure to Implement Abuse and Neglect Reporting Policies for Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to implement its written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for one resident with severe cognitive impairment and significant physical dependence. The resident, an elderly female with unspecified dementia and muscle weakness, was dependent on two staff for bed-to-chair and chair-to-bed transfers and required staff assistance for bathing. She had a history of pain at a surgical amputation site and was receiving PRN Tramadol for moderate to severe pain. A quarterly MDS showed a BIMS score of 3, indicating severely impaired cognition, and care plan documentation confirmed her dependence on staff for transfers and bathing. On a shower day, two CNAs reported that they provided a two-person assist transfer from bed to shower chair and back, with one CNA remaining in the room to fix the bed while the other showered the resident. Both CNAs stated the resident did not complain of pain during the transfers and that she was showered on a shower chair, not standing. In contrast, the resident later reported that “the ladies picked her up from the bottom of her arm,” that she was standing in the shower, and that she felt rib pain at that time but did not tell anyone. The resident’s responsible party stated that the resident began complaining of right-sided pain that afternoon after the shower and that she notified nurses, though she could not recall which nurse. The responsible party further reported that the resident later told her that the CNAs had “pulled her” after the shower. Subsequently, the NP was informed by the family that the resident was complaining of right-sided pain and ordered bilateral rib x‑rays and laboratory tests. Nursing documentation showed that the NP assessed the resident and did not observe bruising or deformity, and that the resident at times denied pain and refused scheduled analgesics. X‑ray results later revealed rib fracture deformities and possible pneumonia. RN D acknowledged receiving the x‑ray report, forwarding it to the NP, and missing the notation of rib fractures, focusing instead on the pneumonia findings. The DON stated that this incident should have been reported to facility administration as soon as RN D received the x‑ray report and that the incident was not reported to the state agency within the required timeframe because the facility was seeking clarification of the x‑ray findings. The Administrator confirmed he was notified after the x‑ray clarification and acknowledged that injuries of unknown origin should be reported within two hours, consistent with the facility’s abuse-prevention policy requiring immediate reporting of all allegations of abuse or neglect to the Administrator and timely reporting to state and federal agencies. The combination of the resident’s report of being pulled and experiencing pain during showering, the subsequent identification of rib fractures, the failure of RN D to report the injury of unknown source to facility management upon receipt of the x‑ray report, and the delay in reporting the possible neglect incident to the state agency demonstrate that the facility did not follow its own written policies and procedures for preventing and responding to potential abuse and neglect. These failures occurred despite the resident’s high level of dependence for transfers and her severe cognitive impairment, and despite the facility’s policy specifying immediate internal reporting and timely external reporting of all allegations of abuse, neglect, and injuries of unknown origin.
Failure to Timely Report Injury of Unknown Origin and Possible Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an injury of unknown origin, as a potential allegation of abuse, neglect, exploitation, or mistreatment, to the State Survey Agency within the required 2-hour timeframe. The resident involved was an elderly female with unspecified dementia of severe degree, as evidenced by a BIMS score of 3, and muscle weakness. Her care plan and MDS documented that she required two-person assistance for bed-to-chair transfers and one-person assistance for bathing/showering. She had a history of pain at a surgical amputation site and was receiving PRN Tramadol for moderate to severe pain. On a Saturday in March, the resident was showered by a CNA who reported that she and another CNA provided a two-person transfer from bed to shower chair and back, and that the resident did not complain of pain during these transfers. Both CNAs stated the resident did not stand in the shower and remained on the shower chair. In contrast, the resident later stated that “the ladies picked her up from the bottom of her arm,” that she was standing in the shower, and that she felt rib pain at that time but did not tell anyone. The resident’s responsible party reported that the resident began complaining of right-sided pain that afternoon, that she notified nursing staff (though she could not recall which nurse), and that the resident received pain medication. The responsible party further stated that the next day the resident was able to say that the CNAs had pulled her after the shower. On a later date in March, the NP rounded and, after being informed by the family that the resident was complaining of right-sided pain, assessed the resident and ordered bilateral rib x‑rays and labs. Nursing documentation that afternoon noted the resident’s complaint of bilateral rib pain and the x‑ray order, and an evening note by the DON documented that the resident denied pain, had full range of motion, and no discoloration. X‑ray results were obtained and sent to the NP, who focused on possible pneumonia and ordered antibiotics and additional treatments. The DON and NP later acknowledged that the rib fracture findings on the x‑ray were initially missed, resulting in delayed recognition of rib fractures. The DON stated that she was notified of the fracture findings the following day, sought clarification from the mobile x‑ray provider due to inconsistent rib descriptions across multiple readings, and then contacted the NP, who arranged for hospital evaluation. The hospital CT scan documented subacute and chronic bilateral rib fracture deformities and bilateral pleural effusions with adjacent airspace disease and atelectasis. Despite the presence of rib fractures of unknown origin in a resident with severe cognitive impairment and dependency for transfers, the DON stated that the incident was not reported to the State agency when the fracture was first identified because the facility was “verifying” the x‑ray results, and that the incident should have been reported to the Administrator and to her as soon as the RN received the x‑ray report. The Administrator stated he was notified by the DON the next day and that injuries of unknown origin should be reported within 2 hours. The facility’s own abuse policy required that all allegations of abuse, neglect, misappropriation, or exploitation be reported immediately to the Administrator and to appropriate State or Federal agencies within applicable timeframes. The surveyors concluded that the facility failed to ensure that this injury of unknown origin, discovered on the date of the x‑ray, was reported immediately, but no later than 2 hours, to the State Survey Agency.
Failure to Recognize Rib Fractures and Follow Care-Plan Transfer Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s expressed choices. The resident was an elderly female with unspecified dementia with severe cognitive impairment, muscle weakness, and dependence on staff for transfers and bathing. Her care plan and MDS documented that she required two-person assistance for chair/bed-to-chair and toilet transfers and one-person assistance for showers. Despite this, the resident later reported that during a shower she was standing and that the CNAs picked her up from under her arms, at which time she felt pain in her ribs but did not immediately report it. The resident’s representative stated that the resident began complaining of right-sided pain after the shower and that she notified nursing staff, though she could not recall which nurse. In the days following the shower, the resident received PRN Tramadol for pain to a surgical site, and on a later date the NP was informed by the family that the resident was complaining of pain to the right side of her body. The NP assessed the resident, did not observe bruising or deformity, and ordered bilateral rib x‑rays along with laboratory tests. Nursing documentation on the same day reflected that the resident denied pain, had full range of motion, and no discoloration was noted. Mobile x‑rays were obtained, and the x‑ray report dated that day showed acute appearing mildly displaced fractures of the right 4th and 5th ribs anterolaterally, with a recommendation to correlate with timing of trauma and pain for age of fractures. However, the nurse who received the x‑ray report acknowledged that she missed the fracture findings and only focused on the pneumonia findings, forwarding the results to the NP without recognizing or acting on the rib fractures. The facility’s DON later reviewed the x‑ray report and noted the fracture findings, but there was confusion regarding which ribs were involved due to differing readings from the mobile x‑ray service. The DON stated that nurses were capable of reading x‑ray reports and were expected to identify and interpret them, yet the fracture results were not recognized or addressed until the following day. During this period, the facility’s policy on Diagnostic Test Results Notification required prompt notification of ordering providers of test results, but the initial fracture findings were not promptly identified or communicated as such. This sequence of events—failure to consistently follow the resident’s transfer and shower assistance requirements as care planned, failure to recognize and act on x‑ray findings of rib fractures, and delay in addressing those findings—constituted the failure to provide treatment and care according to orders, professional standards, the care plan, and the resident’s reported pain and preferences.
Unlabeled IV Vancomycin Bag Hung for a Resident Receiving PICC Infusion
Penalty
Summary
Surveyors identified a deficiency in the administration of IV medications when a resident receiving IV vancomycin via a PICC line had an unlabeled IV medication bag in use. The resident was an adult with osteomyelitis of the vertebra, sacral and sacrococcygeal regions, cellulitis of the lower limb, a stage 4 sacral pressure ulcer, muscle weakness, paraplegia, and a need for assistance with personal care. The care plan included administration of antibiotics per physician orders, and the physician had ordered vancomycin 1 gram IV every 8 hours for sacral wound infection, sacrococcygeal osteomyelitis, and cellulitis. During observation, the IV bag actively infusing into the resident’s PICC line was found to have only a date and nurse’s initials written in black marker, with no resident name, medication dose, frequency, or route indicated. In an interview, the RN who hung the IV bag acknowledged that he had just hung the bag, had thrown away the original label, and was aware that the bag was missing the required medication label information. He stated he knew the bag was supposed to include the resident’s name, dosage, frequency, and route, and acknowledged that failure to label the medication properly could lead to administering the wrong medication to the wrong resident or cause an infection. The DON confirmed that the RN knew he was required to label the IV medication bag and stated that she expected all nurses to label medications appropriately prior to administration, and that it was the administering nurse’s responsibility to verify that everything was labeled correctly. The facility’s policy on administration of IV medications and fluids required verification that the container’s label coincides with the prescriber’s order, including content, dose, prescribed rate, and expiration date of the solution.
Inaccurate MAR Documentation for Controlled Psychotropic Medication
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident receiving psychotropic medication. The resident, an elderly female with late-onset Alzheimer's disease, anxiety disorder, and a mood disorder with manic features, had a care plan addressing psychotropic medication use and an order for alprazolam 1 mg at bedtime. On a January date, the controlled drug record showed that the alprazolam dose was not provided, while the January 2026 MAR documented that the same dose was administered at 8:00 PM by an LVN. The resident’s significant change MDS showed a BIMS score of 01, indicating severe cognitive impairment. During interview, the LVN stated she signed the MAR first for the alprazolam dose, then went to check on the resident and did not administer the medication because the resident was already asleep. She reported that she did not remove the alprazolam from its packaging and documented on the controlled drug record that none was given. The LVN acknowledged that the correct process was to check the resident, retrieve the medication, sign the controlled drug record, administer the medication, and then sign the MAR as administered, and that she should have corrected the MAR entry but did not. The DON confirmed that the LVN was responsible for the medication administration and documentation on that date, that the MAR showed the medication as given while the controlled drug record and narcotic count showed it was not, and that facility policy required documenting on the electronic MAR as medications are administered, not before or after.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart assigned to the 1 and 2 hallways was observed left unlocked and unattended in front of the nurse's station. The cart was under the responsibility of an RN, who was present at the nurse's station but not attending to the cart. Upon being informed by the surveyor, the RN immediately locked the cart. The RN acknowledged responsibility for securing the cart and stated that he was expected to lock it whenever he walked away. He explained that he had unlocked the cart for an auditor, who left it unlocked, and he was unaware that it had not been secured. The Director of Nursing (DON) confirmed that multiple staff, including herself and the Assistant Director of Nursing (ADON), were responsible for ensuring medication carts were locked. The DON stated that staff were expected to lock the cart when leaving it unattended. Facility policy reviewed indicated that all medications must be stored securely, with access limited to authorized personnel, and that medication carts must be locked or attended at all times.
Failure to Maintain Effective Pest Control in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the kitchen. Observations during a tour of the kitchen revealed roaches coming out of the floor drain under the 2-compartment sink. Multiple staff interviews confirmed that the roach problem began when construction of a new parking lot started, and that roaches had been seen in the kitchen since then. Staff reported the issue to the Dietary Manager (DM), who in turn notified the Maintenance Director and the Administrator. The facility had been fumigated the previous week, but roaches continued to be observed in the kitchen. A review of the facility's pest control log showed that the facility had been fumigated monthly from January to May and twice in June for various pests, including roaches. The facility's Infection Control Policy/Procedures required an environment free of pests, with additional pest control visits when problems are detected and prompt reporting to the administrator. Despite these policies, the presence of roaches in the kitchen persisted, indicating that the pest control measures in place were not effective in keeping the kitchen free of pests.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans with measurable objectives and timeframes for two residents, as identified through observation, interview, and record review. For one resident with dementia, muscle weakness, dysphagia, anxiety disorder, and bipolar disorder, the care plan inaccurately documented the presence of a feeding tube and did not address the resident's need for substantial or maximal assistance with eating. Observations showed the resident was unable to feed himself, with his spoon out of reach and food spilled, requiring a CNA to feed him. Staff interviews revealed confusion about the resident's actual needs and the care plan's accuracy, with some staff believing he only needed set-up assistance and others acknowledging he required direct feeding assistance at times. The care plan for this resident was not updated to reflect his fluctuating ability to eat independently and his behavioral issues, such as spitting and refusing assistance. Staff interviews indicated that although CNAs often provided feeding assistance, the care plan did not specify this need, and there was a lack of clarity and communication among staff regarding the resident's actual requirements. The documentation error regarding a feeding tube further contributed to the lack of appropriate interventions in the care plan. For another resident with nicotine dependence and COPD, the care plan did not include any interventions related to smoking, despite the resident being on the facility's smoking list and self-reporting as a smoker. Staff interviews confirmed that the omission was due to a lack of communication and oversight, and the care plan was not updated to address the resident's smoking needs. Facility policy required that such needs be care planned, but this was not done, resulting in the resident's smoking status and related care needs not being addressed in the care plan.
Failure to Label IV Dressing According to Infection Control Standards
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cellulitis, Alzheimer's disease, type 2 diabetes, dementia, muscle weakness, and osteoporosis, was observed to have a peripheral intravenous (IV) line dressing on her right hand that was not labeled with the date and initials as required by facility policy and professional standards. The resident was receiving IV medications and hydration for cellulitis and had orders for both IV fluids and antibiotics. The care plan and physician orders specified monitoring and care of the IV site, including daily checks and dressing changes as needed. During observation, it was noted that while the resident's left wrist IV dressing was properly labeled, the right hand IV dressing lacked both the date and initials. Interviews with the charge nurse, ADON, and DON confirmed that the dressing should have been labeled to track when it was inserted and to ensure timely dressing changes. The charge nurse acknowledged missing the labeling and stated she would remove the unlabeled IV because the duration it had been in place was unknown. Both the ADON and DON reiterated the importance of labeling to prevent infection and ensure compliance with the facility's protocols. Review of facility policies and competency checklists confirmed that labeling IV dressings with the date and initials is a standard requirement, and that IV sites are to be rotated every 72 hours. The failure to label the IV dressing was contrary to both facility policy and professional standards, as documented in the facility's infection prevention and control program and IV administration policies.
Misappropriation of Resident Funds by Former Staff Member
Penalty
Summary
A deficiency occurred when a former Assistant Business Office Manager (ABOM) accessed a resident's bank account information and withdrew funds without the resident's knowledge or consent on 18 separate occasions, resulting in a total loss of $4,671.22. The resident, a male with diagnoses including COPD, muscle weakness, hypertension, and atrial fibrillation, had intact cognitive function as indicated by a BIMS score of 14. The unauthorized transactions took place over several months, and the resident only became aware of the missing funds after noticing discrepancies in his account and seeking assistance from the Business Office Manager (BOM). The facility did not detect the misappropriation until the resident reported the issue, at which point it was discovered that the former ABOM had linked the resident's bank account to her personal Cash App and transferred funds without permission. The ABOM had access to residents' financial information as part of her duties, including assisting with Medicaid applications. The police were involved, and the former ABOM admitted to the theft and was subsequently arrested. The facility's policy states that residents have the right to be free from misappropriation and exploitation, but this was not upheld in this instance.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to two residents who were identified as needing psychiatric evaluation and treatment. Both residents had physician orders for psychiatric consultation following incidents involving behavioral or psychosocial concerns. Despite these orders, there was no evidence in the residents' records of any psychiatric consultation being scheduled, completed, or followed up on. One resident, a male with diagnoses including dementia, cognitive communication deficit, and metabolic encephalopathy, exhibited combative and aggressive behaviors, including an incident where he was physically aggressive toward another resident and a nurse. His care plan included an intervention for psychiatric evaluation and treatment as ordered by the physician. However, the order for psychiatric services was not acted upon, and no documentation of a psychiatric evaluation was found in his record. The second resident, also a male with Alzheimer's disease and cognitive communication deficit, was involved in an altercation where he was kicked by another resident. His care plan addressed potential psychosocial well-being problems and included an order for psychiatric evaluation and treatment. Similar to the first case, there was no documentation of a psychiatric consultation or follow-up. Interviews with facility staff, including the DON and Administrator, confirmed that the social worker responsible for making the referrals did not follow through with the orders, and no psychiatric services were provided as required.
Failure to Administer Eye Drops as Prescribed Following Cataract Surgery
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications as prescribed for a resident following cataract surgery. Specifically, a male resident with a history of dementia, cystoid macular degeneration, and recent cataract surgeries was prescribed prednisolone eye drops for both eyes. The physician's prescription ordered one drop in the right eye twice daily and one drop in the left eye three times daily. However, the facility's physician order and subsequent medication administration records reflected that the resident received the drops in both eyes only twice daily, not adhering to the prescribed frequency for the left eye. Interviews with nursing staff and the Director of Nursing (DON) revealed confusion regarding the correct dosage and frequency of the eye drops. Staff indicated that they could not administer medications without a clear and complete physician's order and would seek clarification if orders were unclear. The DON acknowledged discrepancies between the written prescription and the order entered into the facility's system, noting uncertainty about whether multiple or conflicting orders had been received from different clinics. The resident was also described as resistant to providing post-visit orders, which contributed to the confusion. A review of the facility's medication administration policy confirmed that orders must be accurately implemented as written. Despite the error, the ophthalmic assistant from the prescribing clinic stated that the deviation in administration likely had minimal to no effect on the resident, as there was no evidence of inflammation or negative outcome documented. The deficiency was identified through record review and staff interviews, which confirmed that the resident did not receive the medication as prescribed during the specified period.
Failure to Maintain Accurate DNR Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for a resident regarding their Advance Directives. Specifically, the medical record indicated that the resident had a Do Not Resuscitate (DNR) status, but the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was missing from the resident's medical record. This discrepancy was discovered during a review of the resident's records and interviews with various staff members, including the Assistant Director of Nursing (ADON), Social Worker (SW), and Medical Records Clerk, who all confirmed the absence of the necessary documentation. The resident in question was a 90-year-old female with multiple diagnoses, including essential hypertension, myocardial infarction, dementia, and chronic kidney disease. Despite the resident's clear communication and understanding of her DNR status, as confirmed by her family member and documented in her care plan and physician's orders, the facility failed to have the required OOH-DNR form in the resident's electronic medical record. This oversight was identified when the family member was asked to sign a new DNR form, revealing that the original form from the hospital was not valid for the facility. Interviews with staff members highlighted a lack of clarity and responsibility regarding the completion and verification of DNR forms. The SW, BOM Assistant, and Medical Records Clerk each had different understandings of their roles in the process, leading to the failure to ensure the DNR form was properly completed and filed. The Director of Nursing (DON) acknowledged the error and mentioned that the form might have been deleted from the system by mistake. Eventually, the missing DNR form was found in old medical records, but the initial failure to maintain accurate and complete records posed a significant risk to the resident's expressed wishes regarding resuscitation.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, leading to several deficiencies. One incident involved a Licensed Vocational Nurse (LVN) who did not properly disinfect equipment after providing wound care for a resident. The LVN used alcohol preps instead of disinfectant wipes to clean the bandage scissors, which could lead to cross-contamination and infection. Interviews with the LVN, Director of Nursing (DON), and Assistant Director of Nursing (ADON) confirmed that the correct procedure was not followed, and the facility's infection control policy was not adhered to. Another incident involved the same LVN failing to wear appropriate personal protective equipment (PPE) while providing care for a resident with a peripherally inserted central catheter (PICC) line. The LVN did not wear a gown as required by the Enhanced Barrier Precautions (EBP) and did not follow the proper procedure for changing the PICC line dressing. The LVN also failed to use a bio patch, clean the skin around the insertion site, or change the stat lock and saline/heparin locks as required. Interviews with the DON, Clinical Resource Nurse (CRN), and ADON revealed inconsistencies in the understanding and implementation of the facility's policies regarding PICC line care and EBP. The facility's policies and procedures for infection control, including the use of disinfectant wipes, proper PPE, and specific steps for PICC line dressing changes, were not followed. This lack of adherence to established protocols could lead to cross-contamination, infections, and other health complications for the residents. The facility's infection prevention and control program, as outlined in their documentation, was not effectively implemented, resulting in these deficiencies.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision for Resident #1, a [AGE] year-old female with diagnoses including unspecified Dementia, Muscle weakness, Abnormalities of gait and mobility, and Cognitive communication deficit. Despite being identified as high risk for elopement, Resident #1 managed to leave the facility unnoticed on 12/06/23 and was found approximately 0.2 miles away near a highway by a driver. The facility's investigation revealed that Resident #1 exited through a door in hall 300, despite attempts to redirect her by staff members. The Environmental Manager mentioned that the door alarm was not very loud, and there was a possibility that the landscapers working in the fenced area might have inadvertently allowed Resident #1 to leave.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility staff did not provide Resident #2 with a call light that was within reach. Resident #2, a [AGE] year-old female with hemiplegia and hemiparesis following a cerebral infarction, was observed in bed with her call light placed under her pillow and out of reach. Despite her attempts to reach the call light with her left hand, she was unable to do so. This failure could place residents who utilize call lights at risk for not having their needs met. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that call lights should be accessible to all residents who can use them. The staff acknowledged that if the call light was not accessible, the resident could not receive the necessary assistance, potentially causing stress and anxiety. The facility's policy on call lights also emphasized the importance of placing the call device within the resident's reach before leaving the room. However, this policy was not followed in the case of Resident #2, leading to the identified deficiency.
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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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