THE MEADOWS HEALTH AND REHABILITATION CENTER
For profit - Limited Liability company
184 Beds
SUMMIT LTC
Data: November 2025
3 Immediate Jeopardy citations
Trust Grade
0/100
#1126 of 1168 in TX
Photo by Zachary Carlson
Photo by Zachary Carlson
Photo by Zachary Carlson
1 / 5 photos
Last Inspection: January 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Meadows Health and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns regarding the quality of care provided. Ranking #1126 out of 1168 facilities in Texas places it in the bottom half, and at #82 out of 83 in Dallas County, it is clear that there are very few local options that outperform this facility. The trend is worsening, with the number of issues increasing from 4 in 2024 to 7 in 2025, suggesting ongoing problems that are not being effectively addressed. Staffing is below average with a rating of 2 out of 5 stars and a turnover rate of 56%, which is concerning as it suggests instability among staff. Additionally, the facility has faced $35,731 in fines, and there is less RN coverage than 75% of Texas facilities, meaning residents may not receive adequate oversight for their care. Specific incidents reported include a failure to provide timely pain management for a resident, resulting in her missing over ten doses of medication and experiencing severe pain. Furthermore, the facility has documented critical failures in pharmaceutical services, indicating that staff were not properly trained to manage medication needs effectively. While there may be some aspects of care that are acceptable, the overall picture shows serious weaknesses that families should consider carefully.
- Trust Score
- F
- In Texas
- #1126/1168
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 56% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $35,731 in fines. Lower than most Texas facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Texas. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 4%
Review needed
4 → 7 violations
★☆☆☆☆
1.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Texas average (2.8)
Significant quality concerns identified by CMS
Staff Turnover: 56%
10pts above Texas avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $35,731
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: SUMMIT LTC
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (56%)
8 points above Texas average of 48%
The Ugly 25 deficiencies on record
3 life-threatening 2 actual harm
Jan 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #30 and Resident #48) of 8 residents reviewed for ADLs.
The facility failed to ensure:
- Resident #30 had his fingernails cleaned and trimmed.
- Resident #48 had his fingernails cleaned and trimmed.
These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.
Findings include:
Resident #48
Record review of Resident #48's Quarterly MDS assessment dated [DATE] reflected Resident #48 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included cerebral infarction (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death), muscle weakness, and need for assistance with personal care. Resident #48's BIMS score of 15, which indicated Resident #48 was cognitively intact. The MDS assessment indicated Resident #48 required moderate assistance with personal hygiene.
Record review of Resident #48's Care Plan dated 12/11/24, reflected the following: Problem: Resident requires assistance with all ADL functions . Goal: will maintain a sense of dignity by being clean, dry, odor free and well groomed . Approach: . assist with ADLs PRN .keep fingernails cut to prevent self-scratching .
In an observation on 01/13/25 at 9:36 AM revealed Resident #48 was laying in his bed. The nails on both hands were approximately 0.4cm in length extending from the tip of his fingers. Resident #48 stated he did not like his fingernails long because it would bleed when scratching. He stated he did not tell anybody about his fingernails because they were busy.
In an interview on 01/13/25 at 3:24 PM, CNA L stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA L stated she did not see Resident #48's nails when she did her round. She stated she would do it right then. She stated the risk would be infection control and injury.
Resident #30
Record review of Resident #30's Quarterly MDS assessment dated [DATE] reflected Resident #30 was a [AGE] year-old male admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses included cerebral infarction (a condition that occurs when blood flow to the brain is blocked. The blockage can lead to brain tissue death) affection left side, muscle wasting, hemiplegia (a condition that causes weakness or paralysis on one side of the body) and need for assistance with personal care. Resident #30 was unable to complete the interview for mental status (BIMS), the assessment reflected Resident #30 was cognitively moderately impaired. The MDS assessment indicated Resident #30 was dependent with personal hygiene.
Record review of Resident #30's Care Plan revised 01/02/25, reflected the following: Problem: Resident has an ADL self-care performance deficit and has limited physical mobility related to cerebral infarction . Goal: Resident will maintain current level of . personal hygiene . Approach: . Check nail length and trim and clean as necessary .
In an observation on 01/13/25 at 10:20 AM revealed Resident #30 was laying in his bed. The nails on both hands were approximately 0.4 cm in length extending from the tip of his fingers. The nails were discolored tan and had dark brown colored residue underside and on the nails' bed. Resident #30 was unable to answer questions.
In an interview on 01/13/25 at 3:08 PM, LVN K stated nurses and CNAs were responsible to clean and cut residents' nails. LVN K stated she always cut Resident #30's nails because of his contraction . Splint was in place; fingernails were not digging in the resident's skin. LVN K stated she did not check his nails today. She told resident, she would come back to clean and cut his nails. She stated the risk would be resident's dignity and skin breakdown. Observation on 01/14/25 at 10:05 AM revealed Resident #30's nails on both hands were clean and trimmed.
In an Interview on 01/14/25 at 12:02 PM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated the ADON and the DON would do the routine rounds to monitor. The DON stated residents having long and dirty could be an infection control issue.
Record review of the facility's policy Activities of Daily Living dated December 2018, reflected the following: . It is the policy of this home to assure residents have their activities of daily living met .
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazard...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one of two shower rooms (shower room [ROOM NUMBER]) in the facility's secured unit, reviewed for accidents and hazards.
The facility failed to ensure shower room [ROOM NUMBER] was locked.
These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products.
Findings included:
An observation of the secured unit on 01/13/25 10:55 AM revealed Shower room [ROOM NUMBER] was unlocked when not in use.
An observation of the secured unit on 01/13/25 03:07 PM revealed Shower room [ROOM NUMBER] was unlocked. A cabinet in the shower room was unlocked with the unpadlocked hanging on the door. The cabinet contained multiple bottles of Shampoo, body cleanser, body lotion, and an opened twin [NAME] razor box. The shower area of the shower room had a cleanser that was kept by itself on a table.
In an interview on 1/13/25 at 3:20 PM, CNA F stated he had worked at the facility for about 3 years. He stated that the shower room in the secured unit should always be kept locked when not in use. He stated that residents in the secured unit wandered in and out of rooms and shower room door should be locked to ensure the safety of the residents in the secured unit. He said the charge nurse had the keys to the door, but he was not sure about the cabinet lock key inside the shower room. He said residents could get into personal care products and ingest them accidentally or dispense them on the floor which may result in falls.
In an observation and interview on 01/14/25 09:14 AM with LVN C revealed She said Shower room [ROOM NUMBER]'s door should be locked to ensure the safety of residents. She said personal care items should be secured in the cabinet in the shower room and locked. She said some of the residents in the secured unit were confused and the unlocked door and cabinet posed a risk of accidents to the residents. She stated she had the keys to the shower room but was not certain she had keys to the cabinet lock inside the shower room. She stated she worked in the facility from past 5-6 months and could not remember about received an Inservice from the facility regarding locking shower or storage rooms in the secured unit, however she knew the doors needed to be locked form her nursing background. She stated the risk were exposed to a fall and accident with unlocked shower doors that had personal care items and sharp objects such as razors.
In an interview on 01/15/25 11:30 AM, the DON stated her expectation was the shower room in the secured unit was locked when not in use. She said the doors needed to be secured to ensure the safety of the residents and minimize any possibility of accident or hazard. She stated that residents in the secured unit had low BIMS and were at risk of ingesting personal care items or falls. She said the facility did not have a policy directing accident and hazards but expected all staff to ensure resident safety. She stated that it was her responsibility as a DON to train staff members regarding safety practices in a secured unit, however, could not remember when the last in service was conducted. She stated as a DON, she or her designee conducted daily rounds in all units to ascertain quality of care for the residents. She also stated the charge nurses retain keys to the shower room and the cabinet lock inside the cabinet lock inside the shower room. She stated there was no facility policy directing accident and hazards in a secured unit.
In an interview on 01/15/25 12:23 PM, the Administrator stated he recognized the importance of the doors being locked as there were items in both the shower room and the storage rooms that could pose a risk of harm to residents. He said the facility did not have a policy related to accidents or hazards. He added the DON was responsible for ascertaining training is provided to staff members regarding safety in the secured unit.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two (Residents #3 and #12) of seven residents reviewed for range of motion.
The facility failed to implement interventions to prevent further decline of Resident #3's and Resident #12's contracture to her left hand upon discharge from therapy services.
These failures could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.
Findings included:
Resident #3
Review of Resident #3's Face sheet dated 1/15/25 reflected a [AGE] year-old female with an admission date of 5/3/17.
Review of Resident #3's quarterly MDS assessment, dated 10/12/24, reflected she was severely cognitively impaired with a BIMs of 00. The resident had upper and lower extremity impairment on one side. Resident #3 was started on OT on 9/25/24. Active diagnoses included Seizure Disorder (uncontrolled jerking, loss of consciousness, or other symptoms caused by abnormal electrical activity in the brain), Hemiplegia and Hemiparesis (muscle weakness or partial paralysis on one side of the body) and Other Cerebrovascular disease (can include brain aneurysms, brain bleeds, carotid artery disease and transient ischemic attacks or mini strokes)
Review of Resident #3's physician orders on 1/14/25 revealed no orders for contracture management.
Review of Resident #3's Physician Order Report dated 1/8/2025-1/15/2025 revealed Order dated 1/15/25 Contracture Management: May wear L Resting splint as tolerated to decrease risk of contractures. Twice A Day; 06:00 - 14:00, 14:00 - 22:00 (6:00am - 2:00pm, 2:00pm to 10:00pm) Order dated 1/14/2025 PT/OT/ST to eval and treat if indicated .
Review of Resident #3's comprehensive care plan revised on 10/10/24, reflected, 10/23/24 reflected .Problem Start Date: 04/13/2022 Category: ADLs Functional Status/Rehabilitation Potential The resident has an ADL Self Care Performance Deficit and has limited physical mobility r/t history or cerebral infarction with hemiplegia, rheumatoid arthritis, and dementia Edited: 10/23/2024 . Approach Start Date: 04/13/2022 Approach End Date: 01/23/2025 The resident has contractures of the hands, feet. Provide skin care to keep clean and prevent skin breakdown. Edited: 10/23/2024 . Resident #3 has Contractures to BUE and BLE and is at risk for skin break down, increased pain from affected areas and injury . Approach Start Date: 05/12/2021 Approach End Date: 01/23/2025 Therapy referral as needed Edited: 10/23/2024 .
Review of Resident #3's OT Discharge summary dated [DATE] revealed Skilled Intervention . Orthotic management and training initial Skin checked prior to application of splint with not redness, irritation or breakdown noted .
An observation and interview of Resident #3 on 01/13/25 at 11:40am revealed Resident had left contracted hand and stated they are not doing anything about her hands or legs.
An observation and interview of Resident #3 on 1/14/25 at 10:42am in her room. She had no splint on either hand or stated that they will not help her. She stated the facility only does minimum and would like to leave the facility because they do not help.
An interview with RN D on 1/14/25 at 4:09pm revealed Resident #3 had contracture on her knee however RN D stated she had not noticed contractures on either hand. She did not think she had Resident #3 down for a splint but would check. She stated that monitoring for decline of Resident #3 mobility was continuous and the same for every patient.
An observation of Resident #3 on 1/15/24 at 8:49am in resident's room and she was asleep in her bed. She had no splint to either hand.
An interview with CNA H on 1/15/24 at 9:15am revealed Resident #3 would resist care and would tell people to get out. Resident could move herself on her bed. Resident had a strong dominant side and could pull up but only when she wanted to. Resident could move both her hands. CNA H stated Resident #3 had a splint or had one a long time ago. CNA H stated if she thought there was an issue with a new contracture, she would tell the nurse and the rehab director.
An interview with DOR on 1/14/25 at 3:15pm revealed that residents are initially assessed for OT, PT and speech. They typically received a verbal referral or written referral from the nurses. He stated Resident #3's last evaluation for PT was on 11/12/24 and discharged [DATE]. She was discharged due to plateauing, meaning she had reached her highest potential in therapy. She received PT for range of motion, endurance, flexibility, and strength to improve ADLs. Resident #3 had OT on 9/25/24 for contractor management and positioning. She was discharged from OT on 11/05/24 due to plateauing on some of her range of motion goals. The contracture was on the left side. He stated there was an order for splint on 11/5/24. If a resident had a significant change in condition the nurse would refer her back to therapy. The risk to the resident for not using the splint would be decrease range of motion and increase in contracture.
Resident #12
Record review of Resident #12's quarterly MDS assessment dated , 12/11/24/23 reflected Resident #12 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #12 had diagnoses of Diabetes mellitus (high blood glucose), hypertension, Cerebrovascular accident (blood flow to the brain is cut off), hemiplegia(paralysis of one side of the brain) following cerebral infarction (stroke) affecting left non-dominant side, aphasia, Depression, Muscle weakness (generalized). Resident #12 had a BIMS Score of 9 indicated moderate cognitive impairment. Resident #12 had moderate assistance for Showering and Upper body dressing.
Record review of Resident #12's Comprehensive Care Plan, dated revised 01/14/25 , reflected, Problem: [Resident #12] has Contractures to L [Left] hand and is at risk for skin break down, increased pain from affected areas and injury. Long Term Goal: Contractures will not increase, skin break down will not occur, increased pain will be relieved within one hour of intervention and no injuries will occur over next 90 days. Approach: Contracture Management: May wear L [Left] Resting splint as tolerated to decrease risk of contractures.
Record review of Resident #12 physician order dated 1/14/25 reflected, Contracture Management: May wear L Resting splint as tolerated to decrease risk of contractures. Twice A Day; 06:00 AM - 2:00 PM and 2:00 PM - 10 PM.
In an observation on 01/13/25 10:19 AM revealed Resident #12 was sitting in the hallway in a chair. He had a contracture on his left hand and did not have a splint.
In an observation on 01/14/25 09:38 AM revealed Resident #12 with contractures and no splint on his left hand. Resident #12 was grimacing and held his left wrist with his right hand. Resident was aphasic and answered yes or no questions. Resident nodded no when asked if he could open his left hand. Resident also nodded No when asked if he wore a splint.
In an interview on 1/14/25 at 9:56 AM, LVN C stated she did not know if Resident #12 had a splint for his contractures on left hand. She stated that she was aware he had contractures but did not know if Resident #12 had OT therapy. She stated that she had not splint on his hand for the last 3-4 months since she worked at the facility.
In an observation and Interview on 01/14/25 12:21 PM of Resident#12's left hand, revealed that Resident #12 had splint on his left hand. Resident #12 nodded yes to therapy providing him with the splint.
In an interview on 01/14/25 02:11 PM, the DOR revealed Resident #12 was on OT therapy twice during his stay at the facility for contracture management. He stated Resident #12 was discharged from Occupational Therapy on 12/2/24 due to plateauing on some of her range of motion goals. The DOR revealed after the resident was discharged , it was up to the nurses to continue with the splint order. The DOR revealed the splint was used to protect contractures getting worse, getting indication on the skin and pain as well as increased need for help with ADLs.
In a phone interview on 01/14/25 at 02:39 PM with COTA G revealed Resident #12 had contractures on left hand since admission to the facility. He stated that a splint was provided for his contractures that Resident #12 could wear for 3-4 hours per his comfort level. He stated he was called By LVN C in the morning of 1/14/25 and asked about Resident #12 splint. He stated Resident #12's splint was in the drawers in Resident #12's room and had clothes on top of it.
An interview with DON on 1/15/25 10:07am revealed that the facility handled patients who needed splints for contractures by reviewing recommendations with rehab for the splint. Then during standup meetings the resident's need for splint would be discussed. The orders for a splint would be in the system for all staff to be able to see it. The risk of not following recommendation from rehab on the split for contracture, was that the contractures could increase, and the residents could have an increased need for help with ADLs.
An interview with Administrator on 1/15/25 10:30am revealed that his expectations for managing contractors were for care staff to note them, then notify DON and DON would make referral to rehab. His expectation was that therapy would provide any recommendations to the DON and possibly an order for any recommendations such as splints. Recommendation from rehab were given through the 24-hour report and should be in the Care Plan. MDS would make any updates within 72 hours. If all care staff were unaware of a need, such as a splint for a contracture, it could cause further decline for the resident.
Record review of the facility's Range of Motion Exercises policy, dated December 2018, reflected: It is the policy of this home to provide range of motion for residents in order .7. To prevent contractures from becoming worse if they are already present
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (Med Aid cart 2 west front and Nurses cart 2 Central ) of 3 carts reviewed for pharmacy services.
The facility failed to ensure:
1. LVN P, responsible for Med Aid cart 2 west front, counted controlled drugs every shift change.
2. The Nurses cart 2 Central had 1 insulin pen for Resident #24 with an expired opened date.
This failure could place residents at risk of not having the medication available due to possible drug diversion.
Findings Included:
1. Record review and observation on [DATE] at 12:06 PM of Med Aid cart 2 west front, with MA M revealed missing signatures for Off duty and On duty for [DATE], [DATE] of the narcotic count sheet.
Interview on [DATE] at 12:08 PM, MA M stated nurses and medication aides should have signed the narcotic sheet after counting the narcotics, she stated she did not work on [DATE], and [DATE].
Interview on [DATE] at 1:58 PM, LVN P stated she should have signed the narcotic sheet before and after counting the narcotics on [DATE] and [DATE]. LVN P stated, I counted the narcotics but forgot to sign. LVN P stated this failure could potentially cause a drug diversion.
Interview on [DATE] at 2:10 PM, the DON stated she expected nurses to sign the narcotic count sheet at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated the ADON, and the DON were supposed to check the cart randomly for monitoring.
Review of the facility's policy Narcotic Count dated [DATE], reflected the following: .1. The nurse coming on duty and the nurse going off duty must count and justify narcotics supply for each individual resident at the change of each shift. 2. Each nurse counting must record the date and his/her signature verifying that the count is correct on the [Narcotic Count Sheet], at the beginning and end of each shift .
2.Record review of Resident #24's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia (too many lipids and fats in the blood). She had a BIMS score of 00 indicating her cognition was severely impaired.
Record review of Resident #24's physician's orders dated [DATE] revealed an order for Fiasp Flex Touch U-100 Insulin Novolog (insulin aspart) 100 unit /ml (3ml), administer per sliding scale: If blood sugar is 70 to 149, give 0 units.
If blood sugar is 150 to 199, give 2 units.
If blood sugar is 200 to 299, give 4 units.
If blood sugar is 300 to 399, give 6 units.
If blood sugar is greater than 399, call MD.
Observation on [DATE] at 11:27 AM revealed the Nurses cart 2 Central had a pen of insulin aspart 100 unit /ml for Resident #24 with an expired opened date of [DATE]. Instruction on the pen: discard after 28 days.
Interview on [DATE] at 12:00 PM, LVN K stated the pen of insulin belonged to Resident #24 did have an expired open date. LVN K stated she used the pen of insulin in the morning to give 2 units to Resident #24. She stated she forgot to check the open date on the pen. LVN K stated the purpose for putting an open date was for expiration purposes because the insulin was only good for 28 days. She stated after 28 days the insulin would be ineffective.
Interview on [DATE] at 12:02 PM, the DON stated the insulin flex pens, once opened, needed to be dated because each insulin pen had a specific days shelf life and if not thrown out before that time the insulin could lose its effectiveness. The DON stated the Assistant DON and the DON were supposed to do random checks of the medication carts for monitoring.
Record review of the facility's policy titled Medication - Open Vial Expiration Dates, dated [DATE], revealed in part .Novolog .store under refrigeration until opened. 28 days for opened vial at room temperature or in fridge.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents obtained needed dental services, including routin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure residents obtained needed dental services, including routine dental services for 2 of 2 residents (Resident #8 and Resident #23) reviewed for dental services.
The facility did not obtain routine dental services for Resident #8 and #23.
This failure could place the residents at risk by contributing to mouth pain, difficulty eating and weight loss.
Findings included:
1.Review of Resident #8 Face sheet dated 1/15/25 reflected a [AGE] year-old female with an admission date of 3/11/23.
Review of Resident #8's quarterly MDS assessment, dated 12/11/24, reflected she was moderately cognitively impaired with a BIMs of 12. The resident had no impairment to upper or lower extremities. Resident #8's active diagnoses included Anemia (a condition in which the blood does not have enough healthy red blood cells and hemoglobin), and Essential Hypertension (high blood pressure with no identifiable cause). Resident #8 was on a regular diet. Her funding source was Medicaid. No indication of dental issues.
Review of Resident #8's physician orders on 1/14/25 revealed physician order dated 3/12/23 May have audiological, dental, ophthalmologist, podiatry, psych, wound care consults and treatment if indicated PRN.
Review of Resident #8's comprehensive care plan revised on 10/24/24, reflected .Approach Start Date: 08/23/2023 Approach End Date: 02/08/2025 Dental referral as needed Edited: 12/09/2024 .
Interview with Resident #8 on 01/13/25 at 11:15 AM revealed that she needed to go to dentist due to pain and discomfort of two teeth. She reported she had requested it many times and the facility had not done anything. She reported she talked to administrator and nurses and had been asking to see a dentist for a year.
Interview with RN D on 1/15/25 at 9:28am revealed Resident #8 never told her she needed to see a dentist. Resident #8 had never complained to RN D about mouth pain. She was unaware of when the last time Resident #8 saw a dentist.
Interview with Social Worker on 1/15/25 9:40am revealed no one had requested a referral for dental for Resident #8. She had not been seen at all by a dentist in the past year. All residents at the facility should have been seen by a dentist routinely, but it also depended on their funding source if the dental was covered for each resident. The Dentist, Dental Assistant and Hygienist came to the facility monthly and saw residents on the list the facility provided. The Social Worker stated she compiled the list based on referrals and residents that needed follow-ups.
2.Review of Resident #23 Face sheet dated 1/15/25 reflected a [AGE] year-old female with an admission date of 1/16/22.
Review of Resident #23's quarterly MDS assessment, dated 12/13/24, reflected she was moderately cognitively impaired with a BIMs of 10. The resident had no impairment to upper or lower extremities. Resident #23's active diagnoses Hypertension, Diabetes and Hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). Resident #23's diet should be therapeutic. Her funding source was Medicaid. No dental issues.
Review of Resident #23's Physician Order Report dated 1/15/25 revealed no orders for dentals.
Review of Resident #23's comprehensive care plan revised on 10/10/24, reflected the care plan did not address resident's dental needs.
Interview with Resident #23 on 01/13/25 at 09:37 AM revealed the food served at the facility was hard to eat because she did not have many teeth and the food got stuck in her teeth.
Interview with CNA H on 1/15/25 at 9:24am revealed Resident #23 had never complained about her food or teeth to her.
Interview with RN D on 1/14/25 at 4:03pm revealed Resident #23 had never told her she needed a referral for a dental. Resident #23 had never complained to her about her food. RN D stated whenever residents say they want to see the dentist she would call the doctor, get an order, enter order in Matrix and will let the social worker know. The social worker was the person responsible to make appointments. The dentist came periodically to the facility to see residents that were on the list, but she did not know how often.
Interview with LVN I on 1/15/25 at 9:05am revealed Resident #23 was able to let LVN I know what she needed. Resident #23 had not complained about her teeth or the food. Resident #23 only complained about her head. LVN, I did not know when the last time Resident #23 was seen by a dentist.
Interview with Social Worker on 1/15/25 9:48am revealed that Resident #23 had not been referred to the dentist in the last year. She had not been seen by the dentist in the last year.
Interview with DON on 1/15/25 at 10:013am revealed she was not sure how often residents should see a dentist, however if a resident complained about issues with teeth, they would put in a dental referral to the social worker. DON also stated that Resident #8' and Resident #23's funding sources were Medicaid. The risk to the resident if they did not have routine dentals was, they could have decay, dental issues, and impaired eating.
Interview with Administrator on 1/15/25 at 10:47am revealed the referral process for dentals at the facility was a concern identified; the referral was made to the social worker and then the Social Worker would contact the Dentist to schedule the appointment. He was unsure how often residents should have routine dentals. The risk to the residents if they did not get routine dentals was that they could have tooth loss and decay. He stated he was unaware that Resident #8 and Resident #23 needed to see a dentist.
Interview with DON on 1/15/25 at 3:19pm revealed the facility did not have a policy or process for ancillary services like dental. She stated the nurses were responsible for making referrals if the residents have dental issues and social services was responsible for scheduling the dentals. She stated social services was responsible for ancillary services, such as routine dentals.
Interview with Social Worker on 1/15/25 at 3:26pm revealed she was responsible for tracking ancillary services like physicals, dentals, and podiatry for residents. She reported she hired in December she was making rounds to get information on what residents' needs were. She stated that she was creating her own audit system for dental, physicals and podiatry to keep track of who has been seen and the last time they were seen. She stated that she had scheduled the dentist to come next week so she could develop a communication system with them. She stated she believed her position was vacant for 3-6 months and there was an interim social worker that would come on Sundays to keep things going. She stated she was not aware of how the Facility was tracking ancillary services or what system they had in place.
An interview with Administrator on 1/15/24 3:36pm revealed the social worker's position was vacant for 3 weeks. He stated they had an interim social worker when the last one left, until they found a permanent one. He stated that during the time of transition with the social workers, nurses were responsible for ancillary services. Administrator stated the facility did not have a policy for routine dentals or dental services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facili...
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Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen.
1.
The facility failed to ensure food items in the facility kitchen were covered.
2.
The facility failed to ensure hot holding temperature were above 135 F for three menu items on the lunch service.
This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.
Findings included:
Observation on 1/13/2025 at 9:09 AM of the walk-in freezer revealed food items such as cut zucchini, cut carrots, cinnamon rolls, cooked sausages were left open in a plastic bag inside their individual cardboard boxes.
Observation on 01/13/25 at 11:56 AM of the tray line temperatures for the lunch service revealed [NAME] A was measuring Holding Temperatures before serving the residents. [NAME] A used cleaned thermometer and sanitized the thermometer between each use. [NAME] A took the temperature of the vegetable for the day Turnip greens. The temperature on the thermometer read 129 F. [NAME] A stated that there was not adequate water in the water bath and added more water to the water bath. She proceeded to measure food temperatures for other lunch menu items. [NAME] A measured temperature for mashed potato and pureed vegetable - the temperature for both items read 133F. [NAME] A remarked , The temperatures [133 F for mashed potato and pureed vegetable] were not too low and it was okay to serve. [NAME] A then proceeded to begin lunch service without checking the temperature for Turnip greens.
In an interview on 1/13/2025 at 12:52 PM, [NAME] A revealed it was okay to serve food below 135 as long as it was in the water bath and the water bath was steaming. She added that she was not sure if the temperature needed to be 135 and above before serving to the residents and excused herself to speak with the Dietary Manager. She came back after speaking with the Dietary manager and stated that if the food was not above 135 F , it should not be served to resident since it could make residents sick. She added she knew holding temperature for hot foods should be 135F and above to prevent food borne illnesses , however she was running late for lunch service and proceeded to serve the residents.
In an interview on 01/14/25 01:27 PM with the Dietary Manager revealed her expectation was all foods in the freezer should be covered appropriately. She said everyone in the kitchen , including the Cooks and herself were responsible to ensure that all foods were covered. She stated that even though the food items are in a cardboard box, if the food items are opened , they needed to be sealed tight. She stated that [NAME] A made her aware of serving food items to residents when the holding temperature for items such as vegetable and mashed potato was below 135 F on 1/13/24 Lunch service. She stated that the cook did not put adequate water in the water bath. She stated she expected the cook to take the food items out of the tray line, cover them, put them in the oven and recheck the temperature to ensure it was above 135 F before serving it to the residents. She added uncovered food items and holding hot foods below 135 F could cause food borne illness in residents. She stated she was responsible for providing in-services to the kitchen staff regarding appropriate food storage.
In an interview on 01/15/25 12:15 PM with the Administrator revealed his expectation was all the kitchen staff follow their training and comply with the state and federal food and kitchen sanitation standards that included covering all food items and storing foods at proper temperatures. He stated failure to comply with state or federal regulations for the kitchen could lead to foodborne illness in the residents.
Record review of the facility's policy titled, Food Storage policy revised June 1,2019 reflected, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines .
Record review of the facility's policy titled, Food Storage policy revised June 1,2019 reflected, .Serve all hot foods at a temperature of 135ºF or greater and all cold food at 41ºF or less. Adjust the temperature to account for the time the food will be held prior to service on the steam table and on the tray carts .
Record Review of Review of Food and Drug Administration Food Code, dated 2022, reflected, .3-501.19 Time as a Public Health Control. (A) Except as specified under (D) of this section, if time without temperature control is used as the public health control for a working supply of TIME/TEMPERATURE CONTROL FOR SAFETY FOOD before cooking, or for READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is displayed or held for sale or service . (B) If time without temperature control is used as the public health control up to a maximum of 4 hours: (1) Except as specified in (B)(2), the FOOD shall have an initial temperature of 5°C (41ºF) or less when removed from cold holding temperature control, or 57°C (135°F) or greater when removed from hot holding temperature control.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident (Resident #53) of 8 residents observed for infection control and for 2 of 2 clean linen closets observed for sanitary environment.
The facility failed to ensure:
1. Clean linen closets were kept sanitary.
2. CNA N failed to performed hand hygiene and changed gloves during incontinent care for Resident #53.
These failures could place residents at risk of cross-contamination resulting in infections.
Findings included:
1- An observation of the Clean Linen Closet in the Secured Unit, on 1/13/25 at 10:58 AM revealed an additional cart with a broken bottom most shelf apart from the clean linen cart. The cart had the following items on it: The top shelf contained 2 sets of bagged clothes without names/identification. The second shelf was taped off with several white tapes and had a toothpaste and shaving cream. The third shelf had clean linens on it. The clean linen cart had a black vest hanging on the side of it.
In an observation and interview on 01/13/25 at 11:00 AM with ADON B stated that clean linen closet should only contain clean linens. She was not sure about the other cart in the clean linen closet. She stated that other carts/ vests/ items in the clean linen closet posed a potential risk of cross-contamination.
In an interview on 01/13/25 at 11:15 AM with Laundry Personnel J, she stated that Laundry was responsible for the clean linen cart only. She was not sure who kept the other cart in the clean linen closet and stated it looked like CNA cart. She stated that anything except clean linen can put the residents at a risk of infections.
In an interview on 01/13/25 11:20 AM with CNA E revealed she worked at the facility for about 3 months. She stated that she did not know who put it there or what purpose the other cart had in the clean closet room. She stated she had always seen the other cart in the clean linen closet. She stated that personal hygiene items on the cart if not bagged or any other items were considered dirty and as a potential source of an infection to the residents.
In another observation on 01/14/25 at 10:06 AM in a different unit of the nursing facility, revealed a cardboard box that contained an empty denture box and 2 bottles of mouthwash. The cardboard box was resting near the clean linen cart.
In an interview and observation on 01/14/25 at 10:09 AM, RN D stated that there should not be anything in the clean closet room except residents washed and clean linens. She stated that she did not know who put the box there. She stated that increases the risk of infection to the residents and carried the box out of the clean closet to disposed it off.
In an interview on 01/15/25 at 11:27 AM, the DON stated she expected laundry staff to ensure only clean linens were in the Clean Linen Closets. She said any other items such as personal hygiene items, clothes, carts posed a potential risk of cross-contamination and possible skin issues. She stated that ADON and herself were responsible for ensuring safe practices were utilized to minimize infection control.
2- Record review of Resident #53's Comprehensive MDS assessment dated [DATE] reflected Resident #53 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses included dementia, muscle wasting and atrophy, and need for assistance with personal care. Resident #53's BIMS score of 6, which indicated Resident #53's cognition was severely impaired. The MDS assessment indicated Resident #53 required maximal assistance with toileting and personal hygiene.
Record review of Resident #53's Care Plan dated 10/24/24, reflected the following: Problem: Resident #53 has total urinary incontinence Goal: Resident #53 will remain free from skin breakdown due to incontinence . Approach: . Check resident every 2 hours and as needed incontinence. Change clothing as needed after incontinence episodes .
Observation on 01/14/25 at 10:21 AM revealed CNA N entered Resident #53's room to provide incontinence care. CNA N washed her hands and donned gloves, she unfastened Resident #53's brief, she cleaned his front pubic area with wipes. CNA N changed her gloves without performing any kind of hand hygiene. She rolled the resident on his side revealing medium bowl movement. CNA N wiped the resident's buttock area with peri-wipes, front to back, removing the fecal material. CNA N then removed the soiled brief and with soiled gloves, placed the clean brief under the resident. CNA N changed her gloves without hand hygiene. She rolled the resident on his back onto the clean brief. She applied skin barrier cream to the groins area. She changed gloves without hand hygiene. Once finished, she fastened the resident's brief.
In an interview on 01/14/25 at 10:41 AM, CNA N stated she should have changed her gloves and performed hand hygiene when she went from dirty to clean. CNA A stated failing to provide proper care exposed the resident to infections. She stated she was nervous, and she was trained to sanitize hands between change of gloves.
In an interview on 01/14/25 at 12:02 PM , the DON who was the infection control preventionist, stated she expected the staff to remove their gloves and sanitize their hands when going from dirty to clean. She stated failure to do so would potentially lead to cross-contamination and possible spread of infection. She stated that ADON and herself were responsible for ensuring safe practices were utilized to control infection spread by doing routine rounds and random checks.
Record review of the facility policy titled, Infection Control - Prevention and Control Program dated 12/2018, reflected, The intent of this program is to assure that the home develops, implements, and maintains an Infection Prevention and Control Program to prevent, recognize, and control, to the extent possible, the onset and spread of infection within the facility. The program will: . 5. Properly store, handle, process, and transport linens to minimize contamination .
Record review of the facility's policy, Hand Washing, dated December 2018, reflected, .Employees must wash their hands for at least twenty seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . Before and after assisting a resident with personal care . After removing gloves or aprons .
Dec 2024
3 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0583
(Tag F0583)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy.
1. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media.
This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.
The findings included:
Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Mood Disorder (mental illness that affects a person's emotional state), Insomnia (have trouble falling asleep or staying asleep), Essential Hypertension (high blood pressure), and Restlessness and Agitation.
Record review of Resident #1's admission MDS Assessment, dated 10/16/24, reflected Resident #1 had a BIMS score of 05, which indicated Resident #1 was severely impaired.
Record review of video #1, posted online on 11/30/24, reflected the Activities Assistant as she spoke to Resident #1 reflected the Activities Assistant as she asked the Visitor Why does she (Resident #1) have so many (cupcakes), did you give her those. The visitor asked, She asked for two, can she not have two?. The Activities Assistant can then be heard telling the visitor, She (Resident #1) will make a pig out of herself so don't. The Visitor and Resident #1 sat at the table together at the time of the conversation.
Record review of video #2, posted online on 11/30/24, reflected the Activities Assistant was at one table, and Resident #1 was at a table near the Activities Assistant. The residents were in the dining hall of memory care watching a movie. The Activities Assistant can be heard asking Resident #1, Why don't you go wash your hands?, Resident #1 replied, I am just teasing her (The Visitor), and the Activities Assistant replied to Resident #1, Go wash your hands. Look at the mess you made. An unknown person in the background stated, It's messy, and Activities Assistant can be heard saying, It is. Resident #1 can be seen rolling up the cupcake papers and napkins and stated to the Activities Assistant, I'll go. Resident #1 asked the Activities Assistant, Where can I wash at, and Activities Assistant replied, Try your room, as she starred at Resident #1. Resident #1 replied, Okay, no problem. I messed up. I have to clean up. Resident #1 was observed gathering the crumbs from the cupcake off the table.
In an interview on 12/06/24 at 9:45 AM, Resident #1 stated she was having a good morning, as she sat and spoke with other residents in the dining hall of memory care. When Surveyor asked Resident #1 about Thanksgiving, Resident #1 just started Thanksgiving was good. Resident #1 stated the staff were good and she was treated well. Resident #1 did not remember anything specific about Thanksgiving when Surveyor asked.
In a telephone interview on 12/06/24 at 11:00 AM, Resident #1's Family Member stated she was very mad and upset when she saw the video on social media. The family member stated she and other family members were upset that someone filmed Resident #1, and then it was uploaded to a public, social media application. The Family Member stated Resident #1 did not really remember the incident, but she could only remember eating the cupcakes. The Family Member stated she was upset Resident #1 was recorded in several videos. The Family Member stated the family contacted the DON and asked for the DON to meet them at the facility. The Family Member stated they sent the videos to the DON, and the DON stated she would have been upset as well. The Family Member stated she was not sure how the visitor got in the building, the staff told her they were still investigating to see who the visitor was and why she recorded the videos. The Family Member stated the DON stated the staff were not aware the visitor was recording the resident.
In an interview on 12/06/24 at 12:40 PM, the DON stated the facility only had a policy regarding staff and electronic monitoring or rules for visitors, but she would research to confirm there was no other policy.
In an interview on 12/06/24 at 3:22 PM, the DON stated no residents should be recorded without their permission, it goes against the resident's rights. The Administrator stated he agreed with the DON.
Record review of the facility's policy, titled, Resident Rights, dated 12/01/18, reflected the following:
Privacy and Confidentiality
You have the right to
Privacy, including privacy during visits, phone calls, and while attending to personal needs
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #1) reviewed for abuse.
1. Resident #1 was referred to as a pig and spoken to in a rude manner on a recorded video.
2. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media.
This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity.
The findings included:
Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Mood Disorder (mental illness that affects a person's emotional state), Insomnia (have trouble falling asleep or staying asleep), Essential Hypertension (high blood pressure), and Restlessness and Agitation.
Record review of Resident #1's admission MDS Assessment, dated 10/16/24, reflected Resident #1 had a BIMS score of 05, which indicated Resident #1 was severely impaired.
Record review of video #1, posted online on 11/30/24, reflected the Activities Assistant as she spoke to Resident #1 reflected the Activities Assistant as she asked the Visitor Why does she (Resident #1) have so many (cupcakes), did you give her those. The visitor asked, She asked for two, can she not have two?. The Activities Assistant can then be heard telling the visitor, She (Resident #1) will make a pig out of herself so don't. The Visitor and Resident #1 sat at the table together at the time of the conversation.
Record review of video #2, posted online on 11/30/24, reflected the Activities Assistant was at one table, and Resident #1 was at a table near the Activities Assistant. The residents were in the dining hall of memory care watching a movie. The Activities Assistant can be heard asking Resident #1, Why don't you go wash your hands?, Resident #1 replied, I am just teasing her (The Visitor), and the Activities Assistant replied to Resident #1, Go wash your hands. Look at the mess you made. An unknown person in the background stated, It's messy, and Activities Assistant can be heard saying, It is. Resident #1 can be seen rolling up the cupcake papers and napkins and stated to the Activities Assistant, I'll go. Resident #1 asked the Activities Assistant, Where can I wash at, and Activities Assistant replied, Try your room, as she starred at Resident #1. Resident #1 replied, Okay, no problem. I messed up. I have to clean up. Resident #1 was observed gathering the crumbs from the cupcake off the table.
In an interview on 12/06/24 at 9:45 AM, Resident #1 stated she was having a good morning, as she sat and spoke with other residents in the dining hall of memory care. When Surveyor asked Resident #1 about Thanksgiving, Resident #1 just started Thanksgiving was good. Resident #1 stated the staff were good and she was treated well. Resident #1 did not remember anything specific about Thanksgiving when Surveyor asked.
In an interview on 12/06/24 at 11:00 AM, Resident #1's Family Member stated she was very mad and upset when she saw the video on social media. The family member stated she and other family members were upset that someone filmed Resident #1, but they were also upset about how the Activities Assistant spoke to Resident #1. The Family Member stated Resident #1 did not really remember the incident, but she could only remember eating the cupcakes. The Family Member stated she was upset that the Activities Assistant referred to Resident #1 as a pig. The Family Member stated the family contacted the DON and asked for the DON to meet them at the facility. The Family Member stated they sent the videos to the DON, and the DON stated she would have been upset as well. The Family Member stated the DON and Administrator stated the Activities Assistant was going to be suspended.
A telephone interview on 12/06/24 at 11:40 AM was attempted to the Activities Assistant, but there was no answer and no returned call.
A telephone interview on 12/06/24 at 3:15 PM was attempted to the Visitor, but there was no answer and no returned call.
In an interview on 12/06/4 at 3:22 PM, with the Administrator and the DON, the DON stated the facility did not have a policy regarding social media or recording other than for employees. The DON stated Resident #1 did not recall the incident, but Resident #1's family was not happy about how the Activities Assistant spoke to Resident #1. The DON stated they completed safe surveys with all residents. The DON stated they also completed in-services with the staff and the Activities Assistant was in-serviced and suspended at that time. The DON stated the Activities Assistant should not have spoken to Resident #1 in that manner. The DON stated the risk of staff speaking to the residents in that manner was the well-being and feelings of the resident. The Administrator stated he agreed with what the DON stated.
Record review of the facility's policy titled, Abuse/Reportable Events, dated 12/01/18, reflected the following:
Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility.
Record review of the facility's policy, titled, Resident Rights, dated 12/01/18, reflected the following:
Dignity and Respect
You have the right to
Be treated with dignity, courtesy, consideration, and respect
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for one of one resident (Resident #1) reviewed for abuse.
The facility failed to report when the Activities Assistant spoke rudely to Resident #1 and called her names on Thanksgiving Day, 11/28/24.
This failure could place residents at risk of continued abuse or mistreatment.
Findings included:
Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Mood Disorder (mental illness that affects a person's emotional state), Insomnia (have trouble falling asleep or staying asleep), Essential Hypertension (high blood pressure), and Restlessness and Agitation.
Record review of Resident #1's admission MDS Assessment, dated 10/16/24, reflected Resident #1 had a BIMS score of 05, which indicated Resident #1 was severely impaired.
Record review of video #1, posted online on 11/30/24, reflected the Activities Assistant as she spoke to Resident #1 reflected the Activities Assistant as she asked the Visitor Why does she (Resident #1) have so many (cupcakes), did you give her those. The visitor asked, She asked for two, can she not have two?. The Activities Assistant can then be heard telling the visitor, She (Resident #1) will make a pig out of herself so don't. The Visitor and Resident #1 sat at the table together at the time of the conversation.
Record review of video #2, posted online on 11/30/24, reflected the Activities Assistant was at one table, and Resident #1 was at a table near the Activities Assistant. The residents were in the dining hall of memory care watching a movie. The Activities Assistant can be heard asking Resident #1, Why don't you go wash your hands?, Resident #1 replied, I am just teasing her (The Visitor), and the Activities Assistant replied to Resident #1, Go wash your hands. Look at the mess you made. An unknown person in the background stated, It's messy, and Activities Assistant can be heard saying, It is. Resident #1 can be seen rolling up the cupcake papers and napkins and stated to the Activities Assistant, I'll go. Resident #1 asked the Activities Assistant, Where can I wash at, and Activities Assistant replied, Try your room, as she starred at Resident #1. Resident #1 replied, Okay, no problem. I messed up. I have to clean up. Resident #1 was observed gathering the crumbs from the cupcake off the table.
In an interview on 12/06/24 at 8:55 AM with the DON and the Administrator, The DON stated she became aware of the video and the conversation on the video Thanksgiving weekend. She stated the family of Resident #1 was the one that informed the facility about the video and how the Activities Assistant spoke to Resident #1 on the video. The DON stated the Activities Assistant was suspended pending their investigation. The Administrator stated the incident was not reported to the state. The Administrator did not provide a reason for non-reporting when Surveyor asked.
In a follow-up interview with the Administrator and the DON, on 12/06/24 at 12:40 PM, the Administrator stated the risk of not reporting it within 24 hours was the residents' safety. The DON stated safe surveys were completed, as well as in-services on resident rights, abuse/neglect, and customer service.
A telephone interview on 12/06/24 at 3:15 PM was attempted to the Visitor, but there was no answer and no returned call.
Record review of a document titled, Employee Disciplinary Report, dated 12/04/24, reflected the Activities Assistant was placed on Investigatory Suspension for Activities Assistant depicted on video not providing exceptional customer service to a resident.
Record review of the facility's policy titled, Abuse/Reportable Events, dated 12/01/18, reflected the following:
Reporting: Facility employees must report all allegations of: abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. The facility administrator or designee will report the allegation to HHSC.
If the allegations involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation
If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.
Jan 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a comfortable, homelike environment, with safe ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a comfortable, homelike environment, with safe temperature levels within a range of 71 to 81 degrees Fahrenheit for 5 of 11 rooms (room [ROOM NUMBER], #204 #208, #210, and #213) reviewed for environmental concerns.
On 01/25/24, the facility failed to ensure the temperatures in room [ROOM NUMBER], #204 #208, #210, and #213 were maintained at a safe and comfortable range, even after the facility's boiler had been adjusted.
This failure could place residents at risk of an uncomfortable environment and diminish their quality of life.
Findings included:
An observation on 01/25/24 at 9:10 AM revealed, when entering the facility, the entrance lobby area, the hallways near the entrance, and the conference room all felt cold. The conference room's HVAC unit was blowing cool air. An observation of the thermostat on the wall in the front hallway was observed to be set at 73 degrees Fahrenheit but reflected an inside temperature of 64 degrees Fahrenheit.
In an observation and interview on 01/25/24 starting at 10:25 AM, room [ROOM NUMBER] was observed to feel cool. Resident #1 stated she did not believe the heat was working because the HVAC unit was blowing cold air. The air blowing from the HVAC unit was observed to feel cool. Resident #2 was observed to be sleep in her bed and was tucked under the blankets with only her head out. Resident #2's bed was directly beside the HVAC unit. Resident #1 stated at night the room did get cold, but she was hot natured, so it did not bother her. She stated Resident #2 was her FM and always complained to be cold. She stated the facility was aware and brought her an extra blanket.
In an interview on 01/25/24 at 10:29 AM, Resident #3 was observed laying on her bed with a hoodie and blanket over her. She stated she noticed the heat stopped working on Friday (01/19/24) almost a week ago and the facility still had not fixed the heat. Resident #3 stated during the day when it was warmer outside the room temperature was not as cold, so it was bearable, but at night when the temperature dropped outside it was really cold in the room. Resident #3 stated the facility put those machines in the hallway and told them to keep their doors open to help warm their rooms. She stated it helped, but the HVAC unit in her room was blowing cool air and her bed was right by it. The air blowing from the unit was observed to feel cool. Resident #3 stated she was going to turn the unit off because it was making the room cooler. Resident #3 was observed to turn off the unit. She stated the facility provided her additional blankets. Resident #3's bed was observed to have three blankets.
In an interview on 01/25/24 at 10:37 AM, RN A stated she worked on Saturday (01/20/24) from 6:00 AM to 2:00 PM. She stated when she arrived to work, the facility was very cold, and the residents were complaining. RN A stated contacted the Weekend Supervisor to let him know the heat was not working. She stated the staff provided the residents with extra blankets. RN A stated when she left the facility at 2:00 PM, the heat was still not working. RN A stated when she returned to work on Monday (01/22/24) at 6:00 AM, the big heating units were in the hallways and the hallways were warm. RN A stated some of the residents' rooms were still cold and they were complaining. She stated the rooms did fell cold to her as well, so she told the residents to leave their room door's open so the heat would circulate into their rooms. RN A stated some of the rooms had heat and some did not. She stated the Maintenance Director told her about the heaters in the hallways would help provide heat to the resident's room, so she told them to keep their doors opened. RN A stated it was just in the mornings when the rooms were cold. She stated as the day progressed and the outside temperatures rise, the resident's rooms with no heat would get warmer. RN A stated she did not know the status of the heat and if it was fully repaired.
In an interview on 01/25/24 at 10:51 CNA B stated she believed the facility was still working on repairing the heat, but they provided the big heaters in the hallways to help. CNA B stated she normally worked from 2:00 PM to 10:00 PM and since the facility put out the heaters, she had not received complaints from the residents. She stated because she normally arrived to work during the day at 2:00 PM, it was warmer outside, so she was not receiving complaints, but today she was helping on the morning shift and when she started at 6AM, some of the residents were complaining that they were cold, and it had been cold throughout the night. CNA B stated the rooms were cold to her as well. She stated some of the heaters were not working in some of the rooms, and those residents were the ones complaining of being cold throughout the night. CNA B stated she was providing extra blankets to residents and asked the residents to leave their bedroom doors opened so the heat from the hallway could circulate in their rooms.
In an observation and interview on 01/25/24 starting at 11:02 AM, Resident #4 stated he felt kind of cold right now, but at night it was really cold. Resident #4 stated the HVAC unit in his room was blowing out cool air and had not been working since he returned from the hospital about one week ago. Resident #4 stated he did complain to the facility and was provided an extra blanket. Resident #4 was observed with two blankets on his bed.
In an observation and interview on 01/25/24 starting at 11:06 AM, Resident #5 stated the heat was not working in his room, but he felt okay for right now. Resident #5 was observed to be in bed with two blankets. Resident #5 stated at nighttime his room got really cold. He stated the facility provided him with an additional blanket. Resident #5 stated maintenance was in his room earlier and looked at his HVAC unit. He stated the heat had not been working for a few days.
An observation on 01/25/24 at 11:09 AM revealed room [ROOM NUMBER] felt cold. An interview was attempted with the resident in the room, but they were non-verbal.
In an interview on 01/25/24 at 11:20 AM, the Maintenance Director (MD) stated he was contacted on Sunday (01/21/24) that the heat wasn't working so he went to the facility and the temperature was 70 degrees Fahrenheit. The MD stated he contacted the HVAC company, and they came to the facility on Monday (01/22/24) and Tuesday (01/23/24). He stated they added the portable heaters in the hallways on Monday. The MD stated when the HVAC tech came on Monday, it was discovered the water temperature was set to 70 degrees Fahrenheit, so the air was not blowing out warm. He stated the heat and air ran off the water from the boiler, so the tech increased the temperature to 72. The MD stated he had to reset all the units in each room, which consisted of turning them off for a couple of minutes and then turning them back on. The MD stated the temperature was still not reaching 71 in some rooms, so he called the HVAC company back out on Tuesday. He stated on Tuesday they told him one of the valves was closed on the broiler, so the tech opened it and raised the temperature on the broiler. He stated he thought it was fixed and he was not notified there were still issues overnight. He stated he had been doing spot checks and temping random room and it was above 71. The MD stated he was doing temperatures in the morning about 8:30/9:00 AM and before he left in the evenings about 5/6 PM. He stated had not been temping the rooms at overnight.
In an observation and interview on 01/25/24 from 12:03 to 12:10, the MD temped resident's rooms with a digital thermometer. The MD stated the room temperatures were supposed to be between 71 to 81 degrees Fahrenheit. 11 rooms were temped, and 5 rooms were not between 71 to 81 degrees Fahrenheit. The temperatures were the following:
room [ROOM NUMBER] - 69.5 degrees Fahrenheit
room [ROOM NUMBER] - 69.5 degrees Fahrenheit
room [ROOM NUMBER] - 70.0 degrees Fahrenheit
room [ROOM NUMBER] - 69.5 degrees Fahrenheit
room [ROOM NUMBER] - 70.0 degrees Fahrenheit
The MD stated he would contact the HVAC company to have them come back to the look at the units the resident's rooms.
In an interview on 01/25/24 at 12:27 PM, the Administrator stated he was notified there were issues with the heat and the MD contacted a HVAC company. He stated they added the heaters in the hallways and gave residents extra blankets. He stated the HVAC company came out to the facility on Monday and Tuesday and fixed the issue with the boiler. He stated boiler was not broken, but the temperature needed to be adjusted. He stated if some of the temperatures in room were 69-70 degrees and it was in the afternoon; if the HVAC units in the rooms were not working, he could understand the temperature would drop lower in those rooms overnight. The Administrator stated he was not aware there were still issues with the heat. He stated they had contacted the HVAC company again, and they will back out at the facility either later today or tomorrow morning.
In a phone interview on 01/25/24 at 4:17, the HVAC Technician (Tech) stated he was at the facility on Monday (01/22/24). He stated the facility's boiler temperature was set too low. The HVAC Tech stated the facility's boiler can be safely set between 65-90 degrees Fahrenheit. He stated he believed the facility's boiler was set to 70 degrees, so he increased it to he believed 75 degrees. The HVAC stated the MD started resetting the units in each room, by turning them off and then back on. He stated the MD tested a few and temperature was good, so he left the facility. The HVAC Tech stated the facility called back and said there were still issues, so he stated he had to send another, but he would pull the invoice from Tuesday. The HVAC Tech stated the other Tech found one of the balancing valves on the boiler was closed, so he opened it back up and raised the temperature again on the boiler. The HVAC Tech stated he was not sure of the exact number he adjusted it to, because it was not documented on the invoice. He stated he was contacted by the facility again and was told that some of the rooms were not heating. He stated each unit in the rooms were connected to the boiler and were water source heat pumps, that used the water from the boiler as the condenser. The HVAC Tech stated so whatever temperature the boiler is set to, then the air should be blowing close to that same temperature. He stated it may be off a few degrees off. The HVAC Tech stated for example if you set the boiler temperature at 80 the air should be blowing between 77 to 80 degrees. He stated the boilers were running with no issues, so it sounded like there were issues with the units in the rooms, but he would have to check them out to be sure. The HVAC Tech stated he would be returning to facility tomorrow morning.
Dec 2023
12 deficiencies
3 IJ (3 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0697
(Tag F0697)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #36) of 8 residents reviewed for pain management.
The facility failed to ensure Resident #36 received her scheduled pain medication every six hours as ordered when her supply ran out. Resident #36 received no scheduled or PRN pain medication for more than two days until surveyor inquiry causing her to experience severe pain.
An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems.
This failure placed residents who require pain management at risk of suffering severe pain.
Findings included:
Record review of Resident #36's Face Sheet dated 11/30/23 revealed she was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), congestive heart failure, muscle wasting and atrophy (loss of strength), anxiety disorder due to known physiological condition, pain in right knee, pain in right hip, difficulty walking and muscle spasm.
Record review of Resident #36's most recent MDS assessment dated [DATE] revealed she had a BIMS score of 8 indicating she had moderately impaired cognition. She had occasional pain that occasionally affected her day-to-day activities and made it hard for her to sleep at night. The MDS Assessment also reflected she received routine and PRN pain medications.
Record review of Resident #36's current Care Plan revealed the following entry dated 5/27/21, revised 6/22/23: Category: Medication. The resident is on Pain medication therapy r/t Diabetes Neuropathy. Goal: The resident will be free of any discomfort or adverse side effects from pain medication Approach: Administer medication as ordered: Gabapentin [nerve pain medication]; Norco [hydrocodone-pain medication]; Methocarbamol [muscle relaxer]; hot/cold menthol patch; Tramadol [pain medication] prn, as ordered. Discipline: Nursing, Physician.
Record review of Resident #36's Physician Encounter note dated 11/17/23 completed by NP J reflected the following: Subjective: Chief Complaint: Reports low back pain, BL [bilateral] LE [lower extremity-legs] pain, Rt [right] knee pain, left knee pain.
History of Present Illness: [AGE] year-old long term care resident with PMH significant for DM, cirrhosis, portal HTN [elevated pressure in vein leading to liver], CVA, seen for chronic [lasting a long time] pain management by the request of the primary care team and the nurse. Pt is requesting to take Norco [hydrocodone] routine.
Pain HPI. LOCATION: right leg, left leg, right knee, left knee. QUALITY: aching, throbbing, dull SEVERITY: 9/10 without medication, 4/10 with medication DURATION: chronic in nature. TIMING: intermittent throughout the day. CONTEXT: DJD [degenerative joint disease-worn down tissue at the end of bones] OA [osteoarthritis]
Physical Exam: .Musculoskeletal: general: Pain, weakness. Atrophy: Diffuse Muscular Atrophy .
Plan: .Pain Medication Norco [hydrocodone] 7.5/325 1 tab by mouth Q6 H routine, and Robaxin [methocarbamol] 500 mg 1-tab Q6 H PRN. Will closely monitor. Educated about SE [side effects]
Record review of Resident #36's Physician Order Report printed 11/30/23 revealed the following entries:
Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 8/14/23, End date: 11/28/23. Dx Pain, unspecified.
Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 11/28/23, End date: Open Ended. Dx Pain, unspecified.
Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 8/14/23, End date: 11/28/23. Dx Pain in right knee.
Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 11/28/23, End date: Open Ended. Dx Pain in right knee.
Methocarbamol (muscle relaxer) 500 mg 1 tablet every 8 hours PRN. Start date: 3/16/23-End date: Open ended. Dx Other muscle spasm.
Pain Assessment Q Shift using the Numeric or PAINAD scale. Special Instructions: DOCUMENT RESULTS
Every Shift; Day Shift 06:00 - 14:00, Evening Shift 14:00 - 22:00, Night Shift 22:00 - 06:00
Record review of Resident #36's Medication Administration Record dated 11/1/23 through 11/30/23 revealed the following entries:
Hydrocodone-acetaminophen tablet; 7.5-325 mg Amount to Administer: 1 tablet every 6 hours. DX: Pain, unspecified. The last dose initialed as administered was 11/27/23 at 7:00 PM. The remaining doses reflected the following:
11/28/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: script needed. Signed by LVN F
11/28/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D.
11/28/23 7:00 PM: Not Administered: Drug/Item unavailable. Signed by LVN I.
11/29/23 1:00 AM: Not Administered: Drug/Item unavailable. Signed by LVN H.
11/29/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D.
11/29/23 7:00 PM: Not Administered: Other Comment: med not available, will f/u pharmacy. Signed by LVN G.
11/30/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: awaiting pharmacy delivery. Signed by LVN H.
11/30/23 7:00 AM: No entry.
Methocarbamol 500 mg every 8 Hours-PRN. Three doses were administered on 11/27/23 for pain and muscle spasms. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM].
Tylenol Extra Strength 500 mg Every 6 Hours-PRN. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM].
Pain Assessment Q Shift using the Numeric or PAINAD scale revealed the following entries:
11/28/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
11/28/23 Evening Shift 2:00 PM to 10:00 PM: Pain Level 0 signed by ADON E.
11/28/23 Night Shift 10 PM to 6:00 AM: Pain Level 0 signed by LVN H.
11/29/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
11/29/23 Evening Shift 2:00 PM to 10:00 PM: No entry
11/29/23 Night Shift 10 PM to 6:00 AM: Pain Level 7/10 signed by LVN H.
11/30/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
During an observation and interview on 11/30/23 at 8:15 AM, Resident #36 was in her room, in her bed, she was frowning and asked if state surveyor could check on her medications for her. She stated she had not been getting her medicine for about four days, the staff kept telling her they were waiting for the pharmacy delivery. She stated the medication was hydrocodone for her pain. Resident #36 stated her legs, knees, and feet were very painful and they were not giving her anything for it. She shook her head, motioned toward her legs and rubbed her thighs. She stated she had been complaining of pain to the staff for days and they won't do anything! Resident #36 appeared upset and asked state surveyor to please let me know what is happening because no one will tell me anything! Resident #36's roommate, Resident #22, stated she had heard Resident #36 complaining of pain for the past couple of days and confirmed the staff had been telling her they were waiting for the pharmacy. She stated she did not have any medication issues herself but was worried about her roommate.
During an observation and interview with ADON D and ADON E on 11/30/23 at 8:20 AM, ADON D confirmed she had cared for Resident #36 that week and stated the resident did not have any hydrocodone available on 11/29/23 and she had previously called NP J about it who told her she had sent the prescription to the pharmacy. She stated she called the pharmacy on 11/29/23 and was told it would be on the next delivery, but it was not. ADON D stated today is day two when asked how long she had been out of hydrocodone. ADON D stated Resident #36 was receiving scheduled doses of gabapentin and had muscle relaxers and Tylenol extra strength ordered as needed. When asked about an emergency medication kit (E-kit), ADON D stated they previously had a box and had recently been switched to a Pyxis (machine that distributes medication) and stated they were just filling it. ADON D checked a computer and stated Resident #36's last dose was 11/28/23. She stated she would call the pharmacy and check the E-kit, then walked away. ADON E was working with a medication cart and confirmed it was the cart that contained Resident #36's medications. She stated she was just coming on and did not know anything about her situation. The medication cart was checked with ADON E , and she confirmed there was no hydrocodone available for her. When asked how often medications were re-ordered for residents, ADON E stated she usually reordered when a resident was down to about 15 tablets or half a card just to be safe. She stated she may order them earlier if a resident takes multiple doses per day.
On 11/30/23 at 8:28 AM, ADON D returned and stated she just checked the E-Kit and it only contained hydrocodone 5 mg and 10 mg tablets, and Resident #36 took 7.5 mg tablets. She stated she would contact the pharmacy again.
During a follow-up interview and observation with Resident #36 on 11/30/23 at 8:30 AM, she stated she had not been given anything else for pain. ADON D entered the room during the interview and asked Resident #36 if she was in pain. Resident #36 stated she was hurting bad and rated her pain 10/10. When ADON D told the resident she had muscle relaxers and Tylenol available, Resident #36 replied, You know I don't want that Tylenol, it doesn't do anything! ADON D presented her cell phone and pointed out her text messages and stated she had texted NP J on Monday (11/27/23), told her about the scheduled hydrocodone and informed her there was only one tablet left. When asked if that meant she had not received any doses since Monday, ADON D did not answer, walked away toward her office, and took a phone call. Once off the phone, ADON D stated she had called NP J again on 11/29/23 (Wednesday)and told her the medication was not available. She stated she had checked the E-Kit on 11/29/23 as well but did not inform the pain doctor there were other dose strengths available.
Interview with the DON on 11/30/23 at 9:26 AM revealed she had just been made aware of Resident #36's lack of available hydrocodone that morning. She stated she had just hung up with NP J and the Medical Director and they were getting a one-time order for hydrocodone 10 mg and pulling one from the E-kit while they get the issue resolved. She stated NP J told her she had sent the prescription to the pharmacy earlier in the week. The DON said she called the pharmacy, and they told her they had not received it. She stated the Medical Director was in the process of sending one at that time. The DON explained controlled medications, like hydrocodone, require special triplicate prescriptions. She stated they normally do not require them for refill order as the physicians will order a six-month supply. The facility has authorized agents, like herself, who can order refills. She explained, in this instance, Resident #36 did not have any more refills and required a new prescription. She stated normally either the pharmacy would have notified her, or the Charge Nurse would have notified the physician. The DON stated ADON D told her she had notified NP J prior to the medication running out. The DON stated she knew Resident #36 had Tylenol available as well as muscle relaxers but did not know if any had been administered. She stated she would not consider Tylenol Extra Strength to be a suitable replacement for hydrocodone but Resident #36 had muscle relaxers ordered as well and she expected her pain to be managed in some form or fashion. The DON sated she did not know if Resident #36's pain had been monitored and said it should have been monitored and documented on the MAR. The DON stated she was aware the E-kit had been stocked but, unfortunately, did not have the hydrocodone 7.5 mg dose available that had been ordered for Resident #36. She stated she did not know if anyone had told NP J or the Medical Director there were alternate doses available in the E-kit. The DON stated, if a resident ran out of pain medication, she expected the nurses to check the E-kit, look for back-up medications or other PRN orders available for the resident. If the medications were not effective, she expected the nurses to notify the physician. When asked if she was aware this was a scheduled medication, she stated she was not, but her expectations would be the same. The DON explained medication reorders were discussed in their stand-up meetings. If a nurse ordered a medication, it was written on a board and followed for three days. She was not aware of Resident #36's medication. She stated they had missed their stand-up meeting on 11/28/23 as the survey began that day so that possibly contributed. She stated there was no facility policy for medication reorders, but she expected her nurses to use their judgement and order medications three to five days ahead of time. The DON stated pain monitoring and medication administration were important because she wanted everyone to be comfortable and pain free for quality of life. She stated, My expectation is for my staff to take care of the patients and manage their pain appropriately. The DON stated medications could be ordered any time of day. When asked about other nurses caring for Resident #36 during the last three days, the DON identified LVN G and LVN I as agency nurses and LVN H as working night shift and PRN. She stated she had the same expectations for Agency nurses as she had for facility staff. She stated, I would think they would know as nurses not to let residents go without pain medications. It is very easy to reorder medications in [the computer software]. She stated the failure was of the nurse who first ordered it to notify her and that did not happen. The DON stated they try to keep their E-kit stocked with whatever medications residents have ordered. When it was noted hydrocodone 7.5 mg was not available, they should have tried to contact the physician for an alternative.
Observation and interview with Resident #36 on 11/30/23 at 11:10 AM revealed she was resting in bed with her eyes closed and responded to voice. She stated she had received some medication and was feeling better. She stated she was grateful because I have been asking for days.
During a follow-up interview and observation on 11/30/23 at 11:16 AM, ADON D showed her cell phone with text messages. She identified the texts as being between herself and NP J. The text was dated Monday, 11/27/23 at 1:49 PM and reflected, Hey, [Resident #36] has 2 hydrocodone 7.6-325 can you please reorder? The text response reflected, Ok. ADON D stated she called NP J again today and was told she was sending the triplicate again.
In an interview on 11/30/23 at 11:30 AM, the Administrator and Regional Operations Manager stated there was no policy regarding reordering medications. The Administrator said the medications should have been ordered and they knew the resident had missed 9 doses of regularly scheduled hydrocodone 7.5.mg. They said the nurse should have informed the ADON or DON and the emergency meds should have contained the correct dose for the resident. The Administrator said they failed to have the appropriate medications on hand, in the emergency dispenser, and the staff did not tell anyone they needed to be ordered - they said this was a concern and placed the resident in harm due to missing their pain medication. The Administrator and Regional Operations Manager stated the Regional Nurse Consultant was at home and ill, but they planned to call her.
A telephone interview with the Medical Director on 11/30/23 at 12:08 PM revealed he was Resident #36's attending physician. He stated he had been made aware of an issue with Resident #36's prescription and had just stopped by the facility and provided an order for a one-time dose of pain medication for her while the prescription was sorted out with pharmacy. He stated he was aware she had chronic pain issues which was why he had previously consulted pain management physician. He stated he had not been notified before today there was any issues with her medication availability. He stated Resident #36 had bad arthritis. He stated he had not had any issues or concerns regarding residents receiving their medications.
During an interview on 11/30/23 at 12:12 PM, the DON provided a list of all facility residents receiving pain medications. She stated she had conducted an audit of all medication carts and ensured all residents receiving pain medications had medications available.
During an interview on 11/30/23 at 12:16 PM with ADON D stated she should check pain scales when residents receive pain medications and every shift. She stated she recalled checking Resident #36 on Tuesday, 11/28/23 and she was sleeping so she coded a 0/10. She could not recall what time she checked her or if she checked her again during her shift. She did not respond when asked about coding Resident #36's pain level as a 0 on 11/29/23 and again that morning, even though we had both seen she was in pain. She stated Resident #36 received her last dose of hydrocodone on Tuesday, 11/28/23. ADON D was shown Resident #36's MAR and asked to clarify because the last dose was signed out on Monday, 11/27/23 at 7:00 PM. ADON D stated she would check her computer. She stated she contacted the pharmacy on Wednesday, 11/29/23 and was told the medication had been ordered and was enroute. She stated when it hadn't arrived at the end of her shift, she let LVN F know the medication was not there. She confirmed she did not notify the physician the medications were unavailable.
An interview on 11/30/23 at 2:09 PM with LVN H revealed he worked the 10:00 PM to 6:00 AM shift and had cared for Resident #36. He stated the day shift had reported her hydrocodone was not available. He stated he discussed the situation with Resident #36 and let her know she had PRN medications available. LVN H stated Resident #36 would sometimes sleep through her dose hydrocodone on his shift and he did not recall her complaining of pain during his shift. He stated lately she had been sleeping better since getting scheduled medications. LVN H stated, if scheduled medications were not available for administration, he would report the information on the 24-hour report, but Resident #36's information had already been documented. He stated if she had been acting like she was in pain or throwing a fit he would have called the physician. When asked about his rating of her pain as 7/10 on her MAR for his shift, LVN H stated, What they say, may or may not be what's happening. He stated he provided other means for relief such as repositioning.
In a telephone interview on 11/30/23 at 5:00 PM, NP J confirmed she worked under a pain management specialist. She stated she had received a request to refill Resident #36's hydrocodone on 11/27/23 and sent the prescription to the pharmacy the same day. She stated, for some reason, the prescription did not go through. NP J stated she knew Resident #36 well and she needed her pain medication. She stated the nurses usually sent the request further ahead of time, two to three days before because the pharmacy takes a few days to fill it. She stated the nurses knew they should order it at least two to three days ahead. NP J stated she did not know when Resident #36 received her last dose but when she was told it was still unavailable, she called the pharmacy right away. She stated she did not know the script never went through. NP J stated Resident #36 had orders for [muscle relaxer] and Tylenol as well and the nurses could have administered those. She stated, if the resident was in severe pain, the nurses could have called her for an E-kit order.
Record review of Resident #36's progress notes revealed the most recent nurse's entry was dated 11/13/2023. The following entries were made after surveyor inquiry:
11/29/2023 9:14 AM: [Recorded as Late Entry on 11/30/2023 08:35] This writer spoke with pain management about the resident medication is unavailable, resident rated pain 10/10, contacted pharmacy and was told that medication has been ordered, will continue to monitor for any changes in condition. Signed by ADON D
11/30/2023 8:35 AM: This writer assessed resident this morning, pain medication has not been delivered, resident rated pain 10/10, prn are being given, called the physician and received an onetime dose for Hydrocodone 10-325, also reached out to [NP J] (pain management) but no answer yet, left message, will continue to monitor for any changes of condition. Signed by ADON D.
11/30/23 10:49 AM: Interviewed resident about pain. Resident stated that she is improved somewhat from the administration of muscle relaxer but states her pain is still a 10 in the bilateral [both sides] legs. Informed resident that we had a onetime dose of 10-325 hydrocodone for her. Administered the 10/325 hydrocodone and will re-assess pain. Signed by DON.
11/30/23 11:50 AM: Resident notes with eyes closed, easily aroused, resident denies any pain at this time level 0/10. Signed by ADON E.
Record review of resident #36's Controlled Drug Record for her hydrocodone 7.5-325 mg revealed the final entry was dated 11/27/23 and reflected the last dose was signed out on Monday, 11/27/23 at 8:00 PM. Amount Remaining reflected 0.
Record review of the facility's Policy and Procedure titled Pain Management dated 12/2018 revealed the following:
POLICY It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life.
Procedure
1. Each resident's pain will be assessed using the [Pain Assessment] in the clinical software, upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain. 2. The home promotes residents self-reporting as the most reliable indicator of pain. 3. The home recognizes that a resident's response to pain is subjective and individual .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is. 6. Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e., wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities. 7. The resident's pain will be evaluated routinely each shift. 8. Residents will be re-assessed 30 - 60 minutes after pain management interventions to determine the effectiveness of the intervention. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident's quality of life including complications (i.e., falls, gait disturbance, social isolation). 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures.
Record review of the facility's Policy and Procedure titled Medication-Unusual Occurrences dated 12/2017 revealed the following:
Policy: It is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Definitions: Medication Error: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's order for that medication. Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route of administration, and/or administering to the wrong resident .
Procedure: 1. Unusual occurrences may be medication errors and/or adverse drug reactions. Medication errors and adverse drug reactions shall be immediately reported to the resident's physician and the Director of Nursing .4. Licensed nurses who observe such unusual occurrences are to: a. Take whatever immediate action is necessary to protect the resident's safety and welfare. b. Report the incident immediately to the Director of Nursing. C. Make the appropriate records and notifications required above
The Administrator and Regional Operations Manager were notified on 11/30/23 at 12:51 PM that Immediate Jeopardy and Substandard Quality of Care had been identified in the area of pain management. The IJ Template was provided to the Administrator and DON on 11/30/23 06/08/2023 at 1:12 PM and they were informed the POR was due to HHSC by 2:30 PM on 11/30/23.
The following Plan of Removal submitted by the facility was accepted on 12/1/23 at 2:48 PM and reflected:
11/30/2023 Plan of Removal - F-697 Pain Management Immediate Action Taken
Resident Specific
The facility failed to ensure Resident #36 received her physician-ordered pain medication, Hydrocodone 7.5 milligrams (mg), every 6 hours due to the facility failing to re-order the medication after the last dose was administered on Monday, 11/27 /23, at 7:00 PM. As of 11/30/23, the resident has missed a total of 9 doses. The resident reports having pain at a level of 10 out of 10 on the pain scale.
Residents was immediate assessed for pain on 11/30/2023 by nursing staff.
Physician was notified on 11/30/2023 by DON.
Alternate pain medication order was obtained, and medication was given on 11/30/2023 by nursing staff.
System Changes
Residents will be monitored for pain daily all negative findings will be giving to the DON/designee, Initiated on 11/30/2023 by nursing staff.
100% Audit will be completed of all resident's pain risk to ensure all at risk residents have been identified. Audit initiated on 11/30 by DON/designee and will be completed on 12/1/2023 and report any negative findings.
Every shift pain assessment will be completed by nursing and monitored by DON/designee daily Initiated on 11/30/2023.
Education
Regional Nurse Consultant, RNC provided education to DON/ADON related to re-ordering medication/pain assessment monitoring on 11/30/2023.
DON/Designee will educate nursing staff if a resident is out of pain medication to notify the MD and DON immediately/assess resident/ask for alternate medication/call pharmacy related to when the medication will arrive/ask pharmacy to send out stat if possible. Initiated on 11/30/2023 and each nurse/medication aide will be educated prior to working the floor.
DON/Designee will educate staff on when to re-order medications in a timely manner following the pharmacy medication card system. Initiated on 11/30/2023 and each nurse/medication aide will be educated prior to working the floor.
Monitoring
DON/Designee will randomly interview residents with routine pain medication orders daily x4 weeks on pain level/if pain medication was given. Initiated on 11/30/23 and will end on 12/15/2023.
Residents will have a pain risk observation completed quarterly by the charge nurse with the MDS or significant change of condition.
The facility will ensure residents do not run out of pain medications by the DON/designee conducting a weekly audit for all pain medications to ensure they are ordered timely if needing a [NAME]. The MD will be notified weekly if a [NAME] is needed. The DON/designee will call the pharmacy to ensure the [NAME] was received. DON/designee will check daily to ensure the medication has arrived See Pain Management/Medication Administration policy. The process was initiated on 11/30/2023 and will continue through 12/15/2023.
DON/designee will notify the MD if the provider fails to response within 4 hours of requesting the [NAME]. The process will begin 11/30 and continue through 12/15/2023.
DON/designee will conduct an in-service related to medications available in the e-kit if not available the physician an alternate medication disciplinary action if instruction not followed. Training initiated on 11/30/2023 and each nurse will be educated before working the and will continue until all nurses have been educated.
Administrator and RNC will review each task overseen by DON/Designee weekly beginning 12/1/23 and will end 12/31/2023 to ensure tasks are completed. At that time further review will be conducted through the QAPI process.
Monitoring of the facility's Plan of Removal included the following:
Interview with the DON on 12/1/23 at 3:00 PM revealed in-service training was initiated on 11/30/23 and was still in progress. The training topics included identification of signs and symptoms of pain, how and when to re-order medications, and proper documentation of pain medication administration. In-service content and sign-in sheets were requested for review.
Interviews were conducted on 12/1/23 from 3:40 PM to 4:05 PM with direct care nurses including ADON E, 1 GVN, 1 RN and 2 LVNs. The staff indicated they had been in-serviced on pain management including assessments, medication administration and documentation. The staff stated they would contact the attending physician and DON immediately if any medications were unavailable and check the E-kit for availability. The staff stated medications should be re-ordered one week in advance of the last dose.
In an interview on 12/1/23 at 4:20 PM, ADON D stated she had received in-service training from the Regional Nurse Consultant. She stated medications should be re-ordered a week ahead of the last dose available. ADON D acknowledged the failure to administer scheduled medications was a medication error. She described the risks of medications errors as increased blood pressure for a resident who didn't receive their blood pressure medications and stated residents who did not receive their ordered pain medications as at risk suffering more from pain. She stated the resident's physician and DON should be notified of any medication errors.
In an interview on 12/1/23 at 4:18 PM, the DON revealed she had been in-serviced by the Regional Nurse Consultant and was still in progress in-servicing all staff. She stated medications should be ordered approximately a week in advance. The DON stated all nurses should be assessing residents for pain every shift and as needed. She explained residents should also be assessed around the administration of pain medications and treatments. She stated she was also in-servicing CNAs regarding pain assessments as well. She had instructed them to report any signs of pain to the charge nurse and to come to her if they felt the resident's pain was not managed. She stated she had begun auditing pain assessments and will continue to monitor to ensure completion. The DON stated, if medications were not available, the nurses should check the E-kit for availability. She stated she printed the inventory and placed it with the E-kit machine so that nurses could more quickly check availability. If the medication was not available, the nurse should contact the physician and the DON to obtain an order. The DON stated any medication errors were to be reported immediately to the physician and herself and
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Pharmacy Services
(Tag F0755)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #36) of 8 residents reviewed for pharmacy services.
1. The facility failed to obtain the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication causing her to experience severe pain. The medications were received after surveyor inquiry.
An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems.
This failure could place residents who require pain management at risk of suffering severe pain due to lack of medication availability.
2. The facility failed to prevent an employee with access to controlled medications from diverting an unknown number of Tylenol #3 tablets (a Schedule III narcotice used to treat pain) belonging to Resident #57 from a medication cart.
This failure could place residents at risk for unrelieved pain due to his medication not being readily available.
Findings included:
1. Record review of Resident #36's Face Sheet dated 11/30/23 revealed the resident was re-admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), congestive heart failure, muscle wasting and atrophy (loss of strength), anxiety disorder due to known physiological condition, pain in right knee, pain in right hip, difficulty walking and muscle spasm.
Record review of Resident #36's most recent MDS assessment dated [DATE] revealed she had a BIMS score of 8 indicating she had moderately impaired cognition. She had occasional pain that occasionally affected her day-to-day activities and made it hard for her to sleep at night. The MDS Assessment also reflected she received routine and PRN pain medications.
Record review of Resident #36's current Care Plan revealed the following entry dated 5/27/21, revised 6/22/23: Category: Medication. The resident is on Pain medication therapy r/t Diabetes Neuropathy. Goal: The resident will be free of any discomfort or adverse side effects from pain medication Approach: Administer medication as ordered: Gabapentin [nerve pain medication]; Norco [hydrocodone-pain medication]; Methocarbamol [muscle relaxer]; hot/cold menthol patch; Tramadol [pain medication] prn, as ordered. Discipline: Nursing, Physician.
Record review of Resident #36 Physician Encounter note dated 11/17/23 completed by NP J reflected the following:
Subjective: Chief Complaint: Reports low back pain, BL [bilateral] LE [lower extremity-legs] pain, Rt [right] knee pain, left knee pain.
History of Present Illness: [AGE] year-old long term care resident with PMH significant for DM, cirrhosis, portal HTN [elevated pressure in vein leading to liver], CVA, seen for chronic [lasting a long time] pain management by the request of the primary care team and the nurse. Pt is requesting to take Norco [hydrocodone] routine. Pain HPI. LOCATION: right leg, left leg, right knee, left knee. QUALITY: aching, throbbing, dull SEVERITY: 9/10 without medication, 4/10 with medication DURATION: chronic in nature. TIMING: intermittent throughout the day. CONTEXT: DJD [degenerative joint disease-worn down tissue at the end of bones] OA [osteoarthritis] Physical Exam: .Musculoskeletal: general: Pain, weakness. Atrophy: Diffuse Muscular Atrophy .Plan: .Pain Medication Norco [hydrocodone] 7.5/325 1 tab by mouth Q6 H routine, and Robaxin [methocarbamol] 500 mg 1-tab Q6 H PRN. Will closely monitor. Educated about SE [side effects]
Record review of Resident #36's Physician Order Report printed 11/30/23 revealed the following entries:
Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 8/14/23, End date: 11/28/23. Dx Pain, unspecified.
Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 11/28/23, End date: Open Ended. Dx Pain, unspecified.
Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 8/14/23, End date: 11/28/23. Dx Pain in right knee.
Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 11/28/23, End date: Open Ended. Dx Pain in right knee.
Methocarbamol (muscle relaxer) 500 mg 1 tablet every 8 hours PRN. Start date: 3/16/23-End date:
Open ended. Dx Other muscle spasm.
Pain Assessment Q Shift using the Numeric or PAINAD scale. Special Instructions: DOCUMENT RESULTS Every Shift; Day Shift 06:00 - 14:00, Evening Shift 14:00 - 22:00, Night Shift 22:00 - 06:00
Record review of Resident #36's Medication Administration Record (MAR) dated 11/1/23 through 11/30/23 revealed the following entries:
Hydrocodone-acetaminophen tablet; 7.5-325 mg Amount to Administer: 1 tablet every 6 hours. DX: Pain, unspecified.
The last dose initialed as administered was 11/27/23 at 7:00 PM. The remaining doses reflected the following:
11/28/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: script needed. Signed by LVN F
11/28/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D.
11/28/23 7:00 PM: Not Administered: Drug/Item unavailable. Signed by LVN I.
11/29/23 1:00 AM: Not Administered: Drug/Item unavailable. Signed by LVN H.
11/29/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D.
11/29/23 7:00 PM: Not Administered: Other Comment: med not available, will f/u pharmacy. Signed by LVN G.
11/30/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: awaiting pharmacy delivery. Signed by LVN H.
11/30/23 7:00 AM: No entry.
Methocarbamol 500 mg every 8 Hours-PRN. Three doses were administered on 11/27/23 for pain and muscle spasms. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM].
Tylenol Extra Strength 500 mg Every 6 Hours-PRN. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM].
Pain Assessment Q Shift using the Numeric or PAINAD scale revealed the following entries:
11/28/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
11/28/23 Evening Shift 2:00 PM to 10:00 PM: Pain Level 0 signed by ADON E.
11/28/23 Night Shift 10 PM to 6:00 AM: Pain Level 0 signed by LVN H.
11/29/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
11/29/23 Evening Shift 2:00 PM to 10:00 PM: No entry
11/29/23 Night Shift 10 PM to 6:00 AM: Pain Level 7/10 signed by LVN H.
11/30/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
During an observation and interview on 11/30/23 at 8:15 AM, Resident #36 was in her room, in her bed, she was frowning and asked if state surveyor could check on her medications for her. She stated she had not been getting her medicine for about four days, the staff kept telling her they were waiting for the pharmacy delivery. She stated the medication was hydrocodone for her pain. Resident #36 stated her legs, knees, and feet were very painful and they were not giving her anything for it. She shook her head, motioned toward her legs and rubbed her thighs. She stated she had been complaining of pain to the staff for days and they won't do anything! Resident #36 appeared upset and asked state surveyor to please let me know what is happening because no one will tell me anything! Resident #36's roommate, Resident #22, stated she had heard Resident #36 complaining of pain for the past couple of days and confirmed the staff had been telling her they were waiting for the pharmacy. She stated she did not have any medication issues herself but was worried about her roommate.
During an interview with ADON D and ADON E on 11/30/23 at 8:20 AM, ADON D confirmed she had cared for Resident #36 that week and stated the resident did not have any hydrocodone available on 11/29/23 and she had previously called NP J about it who told her she had sent the prescription to the pharmacy. She stated she called the pharmacy on 11/29/23 and was told it would be on the next delivery, but it was not. ADON D stated today is day two when asked how long she had been out of hydrocodone. ADON D stated Resident #36 was receiving scheduled doses of gabapentin and had muscle relaxers and Tylenol extra strength ordered as needed. When asked about an emergency medication kit (E-kit), ADON D stated they previously had a box and had recently been switched to a Pyxis (machine that distributes medication) and stated they were just filling it. ADON D checked a computer and stated Resident #36's last dose was 11/28/23. She stated she would call the pharmacy and check the E-kit, then walked away. ADON E was working with a medication cart and confirmed it was the cart that contained Resident #36's medications. She stated she was just coming on and did not know anything about her situation. The medication cart was checked with ADON E, and she confirmed there was no hydrocodone available for her. When asked how often medications were re-ordered for residents, ADON E stated she usually reordered when a resident was down to about 15 tablets or half a card just to be safe. She stated she may order them earlier if a resident takes multiple doses per day.
On 11/30/23 at 8:28 AM, ADON D returned and stated she just checked the E-Kit and it only contained hydrocodone 5 mg and 10 mg tablets, and Resident #36 took 7.5 mg tablets. She stated she would contact the pharmacy again.
During a follow-up interview and observation with Resident #36 on 11/30/23 at 8:30 AM, she stated she had not been given anything else for pain. ADON D entered the room during the interview and asked Resident #36 if she was in pain. Resident #36 stated she was hurting bad and rated her pain 10/10. When ADON D told the resident she had muscle relaxers and Tylenol available, Resident #36 replied, You know I don't want that Tylenol, it doesn't do anything! ADON D presented her cell phone and pointed out her text messages and stated she had texted NP J on Monday (11/27/23), told her about the scheduled hydrocodone and informed her there was only one tablet left. When asked if that meant she had not received any doses since Monday, ADON D did not answer, walked away toward her office, and took a phone call. Once off the phone, ADON D stated she had called NP J again on 11/29/23 (Wednesday)and told her the medication was not available. She stated she had checked the E-Kit on 11/29/23 as well but did not inform the pain doctor there were other dose strengths available.
Interview with the DON on 11/30/23 at 9:26 AM revealed she had been just made aware of Resident #36's lack of available hydrocodone that morning. She stated she had just hung up with NP J and the Medical Director and they were getting a one-time order for hydrocodone 10 mg and pulling one from the E-kit while they get the issue resolved. She stated NP J told her she had sent the prescription to the pharmacy earlier in the week. The DON said she called the pharmacy, and they told her they had not received it. She stated the Medical Director was in the process of sending one at that time. The DON explained controlled medications, like hydrocodone, require special triplicate prescriptions. She stated they normally do not require them for refill order as the physicians will order a six-month supply. The facility has authorized agents, like herself, who can order refills. She explained, in this instance, Resident #36 did not have any more refills and required a new prescription. She stated normally either the pharmacy would have notified her, or the Charge Nurse would have notified the physician. The DON stated ADON D told her she had notified NP J prior to the medication running out.
The DON stated she knew Resident #36 had Tylenol available as well as muscle relaxers but did not know if any had been administered. She stated she would not consider Tylenol Extra Strength to be a suitable replacement for hydrocodone but Resident #36 had muscle relaxers ordered as well and she expected her pain to be managed in some form or fashion. The DON sated she did not know if Resident #36's pain had been monitored and said it should have been monitored and documented on the MAR. The DON stated she was aware the E-kit had been stocked but, unfortunately, did not have the hydrocodone 7.5 mg dose available that had been ordered for Resident #36. She stated she did not know if anyone had told NP J or the Medical Director there were alternate doses available in the E-kit. The DON stated, if a resident ran out of pain medication, she expected the nurses to check the E-kit, look for back-up medications or other PRN orders available for the resident. If the medications were not effective, she expected the nurses to notify the physician. When asked if she was aware this was a scheduled medication, she stated she was not, but her expectations would be the same.
The DON explained medication reorders were discussed in their stand-up meetings. If a nurse ordered a medication, it was written on a board and followed for three days. She was not aware of Resident #36's medication. She stated they had missed their stand-up meeting on 11/28/23 as the survey began that day so that possibly contributed. She stated there was no facility policy for medication reorders, but she expected her nurses to use their judgement and order medications three to five days ahead of time. The DON stated pain monitoring and medication administration were important because she wanted everyone to be comfortable and pain free for quality of life. She stated, My expectation is for my staff to take care of the patients and manage their pain appropriately.
The DON stated medications could be ordered any time of day. When asked about other nurses caring for Resident #36 during the last three days, the DON identified LVN G and LVN I as agency nurses and LVN H as working night shift and PRN. She stated she had the same expectations for Agency nurses as she had for facility staff. She stated, I would think they would know as nurses not to let residents go without pain medications. It is very easy to reorder medications in [the computer software]. She stated the failure was of the nurse who first ordered it to notify her and that did not happen. The DON stated they try to keep their E-kit stocked with whatever medications residents have ordered. When it was noted hydrocodone 7.5 mg was not available, they should have tried to contact the physician for an alternative.
Observation and interview with Resident #36 on 11/30/23 at 11:10 AM revealed she was resting in bed with her eyes closed and responded to voice. She stated she had received some medication and was feeling better. She stated she was grateful because I have been asking for days.
During a follow-up interview on 11/30/23 at 11:16 AM, ADON D showed her cell phone with text messages. She identified the texts as being between herself and NP J. The text was dated Monday, 11/27/23 at 1:49 PM and reflected, Hey, [Resident #36] has 2 hydrocodone 7.5-325 can you please reorder? The text response reflected, Ok. ADON D stated she called NP J again today and was told she was sending the triplicate again.
In an interview on 11/30/23 at 11:30 AM, the Administrator and Regional Operations Manager stated there was no policy regarding reordering medications. The Administrator said the medications should have been ordered and they knew the resident had missed 9 doses of regularly scheduled hydrocodone 7.5.mg. They said the nurse should have informed the ADON or DON and the emergency meds should have contained the correct dose for the resident. The Administrator said they failed to have the appropriate medications on hand, in the emergency dispenser, and the staff did not tell anyone they needed to be ordered - they said this was a concern and placed the resident in harm due to missing their pain medication. The Administrator and Regional Operations Manager stated the Regional Nurse Consultant was at home and ill.
A telephone interview with the Medical Director on 11/30/23 at 12:08 PM revealed he was Resident #36's attending physician. He stated he had been made aware of an issue with Resident #36's prescription and had just stopped by the facility and provided an order for a one-time dose of pain medication for her while the prescription was sorted out with pharmacy. He stated he was aware she had chronic pain issues which was why he had previously consulted pain management physician. He stated he had not been notified before today there was any issues with her medication availability. He stated Resident #36 had bad arthritis. He stated he had not had any issues or concerns regarding residents receiving their medications.
During an interview on 11/30/23 at 12:12 PM, the DON provided a list of all facility residents receiving pain medications. She stated she had conducted an audit of all medication carts and ensured all residents receiving pain medications had medications available.
During an interview on 11/30/23 at 12:16 PM with ADON D stated she should check pain scales when residents receive pain medications and every shift. She stated she recalled checking Resident #36 on Tuesday, 11/28/23 and she was sleeping so she coded a 0/10. She could not recall what time she checked her or if she checked her again during her shift. She did not respond when asked about coding Resident #36's pain level as a 0 on 11/29/23 and again that morning, even though we had both seen she was in pain. She stated Resident #36 received her last dose of hydrocodone on Tuesday, 11/28/23. ADON D was shown Resident #36's MAR and asked to clarify because the last dose was signed out on Monday, 11/27/23 at 7:00 PM. ADON D stated she would check her computer. She stated she contacted the pharmacy on Wednesday, 11/29/23 and was told the medication had been ordered and was enroute. She stated when it hadn't arrived at the end of her shift, she let LVN F know the medication was not there. She confirmed she did not notify the physician the medications were unavailable.
An interview on 11/30/23 at 2:09 PM with LVN H revealed he worked the 10:00 PM to 6:00 AM shift and had cared for Resident #36. He stated the day shift had reported her hydrocodone was not available. He stated he discussed the situation with Resident #36 and let her know she had PRN medications available. LVN H stated Resident #36 would sometimes sleep through her dose hydrocodone on his shift and he did not recall her complaining of pain during his shift. He stated lately she had been sleeping better since getting scheduled medications. LVN H stated, if scheduled medications were not available for administration, he would report the information on the 24-hour report, but Resident #36's information had already been documented. He stated if she had been acting like she was in pain or throwing a fit he would have called the physician. When asked about his rating of her pain as 7/10 on her MAR for his shift, LVN H stated, What they say, may or may not be what's happening. He stated he provided other means for relief such as repositioning. LVN H stated medications should be ordered 3-5 days ahead of time to ensure availability.
In a telephone interview on 11/30/23 at 5:00 PM, NP J confirmed she worked under a pain management specialist. She stated she had received a request to refill Resident #36's hydrocodone on 11/27/23 and sent the prescription to the pharmacy the same day. She stated, for some reason, the prescription did not go through. NP J stated she knew Resident #36 well and she needed her pain medication. She stated the nurses usually sent the request further ahead of time, two to three days before because the pharmacy takes a few days to fill it. She stated the nurses knew they should order it at least two to three days ahead. NP J stated she did not know when Resident #36 received her last dose but when she was told it was still unavailable, she called the pharmacy right away. She stated she did not know the script never went through. NP J stated Resident #36 had orders for [muscle relaxer] and Tylenol as well and the nurses could have administered those. She stated, if the resident was in severe pain, the nurses could have called her for an E-kit order.
Record review of Resident #36's progress notes revealed the most recent nurse's entry was dated 11/13/2023. The following entries were made after surveyor inquiry:
11/29/2023 9:14 AM: [Recorded as Late Entry on 11/30/2023 08:35] This writer spoke with pain management about the resident medication is unavailable, resident rated pain 10/10, contacted pharmacy and was told that medication has been ordered, will continue to monitor for any changes in condition. Signed by ADON D
11/30/2023 8:35 AM: This writer assessed resident this morning, pain medication has not been delivered, resident rated pain 10/10, prn are being given, called the physician and received an onetime dose for Hydrocodone 10-325, also reached out to [NP J] (pain management) but no answer yet, left message, will continue to monitor for any changes of condition. Signed by ADON D.
11/30/23 10:49 AM: Interviewed resident about pain. Resident stated that she is improved somewhat from the administration of muscle relaxer but states her pain is still a 10 in the bilateral [both sides] legs. Informed resident that we had a onetime dose of 10-325 hydrocodone for her. Administered the 10/325 hydrocodone and will re-assess pain. Signed by DON.
11/30/23 11:50 AM: Resident notes with eyes closed, easily aroused, resident denies any pain at this time level 0/10. Signed by ADON E.
Record review of resident #36's Controlled Drug Record for her hydrocodone 7.5-325 mg revealed the final entry was dated 11/27/23 and reflected the last dose was signed out on Monday, 11/27/23 at 8:00 PM. Amount Remaining reflected 0.
Record review of the facility's Policy and Procedure titled Medication Administration dated 12/2018 revealed the following:
POLICY
It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.
PROCEDURE
1. Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration .10. If a dose of regularly scheduled medication is withheld or refused, the space provided on the front of the MAR for that dosage administration is initialed and circled. The physician will be notified if medication is routinely refused.
Record review of the facility's Policy and Procedure titled Pain Management dated 12/2018 revealed the following:
POLICY It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life.
Procedure
1. Each resident's pain will be assessed using the [Pain Assessment] in the clinical software, upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is .10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures.
Record review of the facility's Policy and Procedure titled Medication-Unusual Occurrences dated 12/2017 revealed the following:
Policy: It is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Definitions: Medication Error: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's order for that medication. Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route of administration, and/or administering to the wrong resident .
Procedure: 1. Unusual occurrences may be medication errors and/or adverse drug reactions. Medication errors and adverse drug reactions shall be immediately reported to the resident's physician and the Director of Nursing .4. Licensed nurses who observe such unusual occurrences are to: a. Take whatever immediate action is necessary to protect the resident's safety and welfare. b. Report the incident immediately to the Director of Nursing. C. Make the appropriate records and notifications required above
The Administrator and Regional Operations Manager were notified on 11/30/23 at 12:51 PM that Immediate Jeopardy had been identified in the area of pharmacy services. The IJ Template was provided to the Administrator and DON on 11/30/23 06/08/2023 at 1:12 PM and they were informed the POR was due to HHSC by 2:30 PM on 11/30/23.
The following Plan of Removal submitted by the facility was accepted on 12/1/23 at 2:48 PM and reflected:
11/30/2023 Plan of Removal - F-755 Pharmacy Services Immediate Action Taken
Resident Specific
The facility failed to ensure Resident #36 received her physician-ordered pain medication, Hydrocodone 7.5 milligrams (mg), every 6 hours due to the facility failing to re-order the medication after the last dose was administered on Monday, 11/27 /23, at 7:00 PM. As of 11/30/23, the resident has missed a total of 9 doses. The resident reports having pain at a level of 10 out of 10 on the pain scale.
100% orders and medications were immediately audited for medication availability by DON/ADON's no negative findings.
System Changes
DON/designee will audit medication carts and matching any new orders weekly for medication availability. Audit was initiated on 11/30/2023 and completed on 11/30/2023 by 5 p.m.
Pharmacy reordering system will be followed during medication re-ordering and was initiated 11/30/23 and ongoing.
E-Kit will be available for charge nurses to use if medication is not available from the pharmacy or if the physician will order alternative drug until the medication is available from the pharmacy.
DON/designee will review all medication weekly for medication availability and for re-ordering this will be conducted simultaneously. Don/Designee conducted review for medication availability on 11/30/2023 and competed the process by 4 p.m. on 11/30/23.
Education
Regional Nurse Consultant, RNC educated DON/ADON on when to re-order medications. Education was conducted on 11/30/2023 and completed on 11/30/2023.
DON/Designee will educate LVN/RN/CMA on when to re-order medications. Education was initiated on 11/30/2023 at 2p.m. and will continue until all LVN/RN/CMA are educated and prior to their next shift.
Monitoring
DON/Designee will randomly check all medication carts for matching medication and orders daily for medication availability. Monitoring began on 11/30/2023 and will end 12/14/2023.
DON/designee will audit all medication carts monthly for medication availability matching orders with medication. Monitoring began 11/30/23.
DON/Designee will pull medication availability report daily. Process was initiated on 11/30/2023 and will continue daily until 12/31/2023.
Administrator and RNC will review each task overseen by DON/ Designee weekly beginning 12/1/ 23 and will end 12/31/2023 to ensure tasks are completed. At that time further review will be conducted through the QAPI process.
Monitoring of the facility's Plan of Removal included the following:
Interview with the DON on 12/1/23 at 3:00 PM revealed in-service training was initiated on 11/30/23 and was still in progress. The training topics included identification of signs and symptoms of pain, how and when to re-order medications, and proper documentation of pain medication administration. In-service content and sign-in sheets were requested for review.
Interviews were conducted on 12/1/23 from 3:40 PM to 4:05 PM with direct care nurses including ADON E, 1 GVN, 1 RN and 2 LVNs. The staff indicated they had been in-serviced on pain management including assessments, medication administration and documentation. The staff stated they would contact the attending physician and DON immediately if any medications were unavailable and check the E-kit for availability. The staff stated medications should be re-ordered one week in advance of the last dose.
In an interview on 12/1/23 at 4:20 PM, ADON D stated she had received in-service training from the Regional Nurse Consultant. She stated medications should be re-ordered a week ahead of the last dose available. ADON D stated the failure to administer scheduled medications was a medication error. She stated residents who did not receive their ordered pain medications are at risk of suffering more from pain. She stated the resident's physician and DON should be notified of any medication errors.
In an interview on 12/1/23 at 4:18 PM, the DON revealed she had been in-serviced by the Regional Nurse Consultant and was still in progress in-servicing all staff. She stated medications should be ordered approximately a week in advance. The DON stated all nurses should be assessing residents for pain every shift and as needed. She stated residents should also be assessed around the administration of pain medications and treatments. She stated she was also in-servicing CNAs regarding pain assessments as well. She had instructed them to report any signs of pain to the charge nurse and to come to her if they felt the resident's pain was not managed. She stated she had begun auditing pain assessments and will continue to monitor to ensure completion. The DON stated, if medications were not available, the nurses should check the E-kit for availability. She stated she printed the inventory and placed it with the E-kit machine so that nurses could more quickly check availability. If the medication was not available, the nurse should contact the physician and the DON to obtain an order. The DON stated any medication errors were to be reported immediately to the physician and herself and monitor the resident. She stated she was responsible for investigating and documenting the errors. The DON stated all staff currently working had received their in-service training. All staff not yet trained will receive in-service prior to beginning their next shift.
During an interview on 12/1/23 at 4:50 PM, the Regional Director of Operations stated he felt all the problems identified came down to communication. He stated medication issues should start with the nurse and move up the chain. He stated he had periodically attended the facility stand-up meeting and planned to attend more regularly a[TRUNCATED]
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0760
(Tag F0760)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medicati...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for one (Resident #36) of 8 residents reviewed for pharmacy services .
The facility failed to administer the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication.
An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems.
This failure could result in residents experiencing severe pain, not receiving medications prescribed by their physician and decreased quality of life.
Findings included:
Record review of Resident #36's Face Sheet dated 11/30/23 revealed she was re-admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), congestive heart failure, muscle wasting and atrophy (loss of strength), anxiety disorder due to known physiological condition, pain in right knee, pain in right hip, difficulty walking and muscle spasm.
Record review of Resident #36's most recent MDS assessment dated [DATE] revealed she had a BIMS score of 8 indicating she had moderately impaired cognition. She had occasional pain that occasionally affected her day-to-day activities and made it hard for her to sleep at night. The MDS Assessment also reflected she received routine and PRN pain medications.
Record review of Resident #36's current Care Plan revealed the following entry dated 5/27/21, revised 6/22/23: Category: Medication. The resident is on Pain medication therapy r/t Diabetes Neuropathy. Goal: The resident will be free of any discomfort or adverse side effects from pain medication Approach: Administer medication as ordered: Gabapentin [nerve pain medication]; Norco [hydrocodone-pain medication]; Methocarbamol [muscle relaxer]; hot/cold menthol patch; Tramadol [pain medication] prn, as ordered. Discipline: Nursing, Physician.
Record review of Resident #36 Physician Encounter note dated 11/17/23 completed by NP J reflected the following: Subjective: Chief Complaint: Reports low back pain, BL [bilateral] LE [lower extremity-legs] pain, Rt [right] knee pain, left knee pain.
History of Present Illness: [AGE] year-old long term care resident with PMH significant for DM, cirrhosis, portal HTN [elevated pressure in vein leading to liver], CVA, seen for chronic [lasting a long time] pain management by the request of the primary care team and the nurse. Pt is requesting to take Norco [hydrocodone] routine.
Pain HPI. LOCATION: right leg, left leg, right knee, left knee. QUALITY: aching, throbbing, dull SEVERITY: 9/10 without medication, 4/10 with medication DURATION: chronic in nature. TIMING: intermittent throughout the day. CONTEXT: DJD [degenerative joint disease-worn down tissue at the end of bones] OA [osteoarthritis]
Physical Exam: .Musculoskeletal: general: Pain, weakness. Atrophy: Diffuse Muscular Atrophy .
Plan: .Pain Medication Norco [hydrocodone] 7.5/325 1 tab by mouth Q6 H routine, and Robaxin [methocarbamol] 500 mg 1 tab Q6 H PRN. Will closely monitor. Educated about SE [side effects]
Record review of Resident #36's Physician Order Report printed 11/30/23 revealed the following entries:
Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 8/14/23, End date: 11/28/23. Dx Pain, unspecified.
Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 11/28/23, End date: Open Ended. Dx Pain, unspecified.
Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 8/14/23, End date: 11/28/23. Dx Pain in right knee.
Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 11/28/23, End date: Open Ended. Dx Pain in right knee.
Methocarbamol (muscle relaxer) 500 mg 1 tablet every 8 hours PRN. Start date: 3/16/23-End date: Open ended. Dx Other muscle spasm.
Pain Assessment Q Shift using the Numeric or PAINAD scale. Special Instructions: DOCUMENT RESULTS
Every Shift; Day Shift 06:00 - 14:00, Evening Shift 14:00 - 22:00, Night Shift 22:00 - 06:00
Record review of Resident #36's Medication Administration Record (MAR) dated 11/1/23 through 11/30/23 revealed the following entries:
Hydrocodone-acetaminophen tablet; 7.5-325 mg Amount to Administer: 1 tablet every 6 hours. DX: Pain, unspecified. The last dose initialed as administered was 11/27/23 at 7:00 PM. The remaining doses reflected the following:
11/28/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: script needed. Signed by LVN F
11/28/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D.
11/28/23 7:00 PM: Not Administered: Drug/Item unavailable. Signed by LVN I.
11/29/23 1:00 AM: Not Administered: Drug/Item unavailable. Signed by LVN H.
11/29/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D.
11/29/23 7:00 PM: Not Administered: Other Comment: med not available, will f/u pharmacy. Signed by LVN G.
11/30/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: awaiting pharmacy delivery. Signed by LVN H.
11/30/23 7:00 AM: No entry.
Methocarbamol 500 mg every 8 Hours-PRN. Three doses were administered on 11/27/23 for pain and muscle spasms. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM].
Tylenol Extra Strength 500 mg Every 6 Hours-PRN. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM].
Pain Assessment Q Shift using the Numeric or PAINAD scale revealed the following entries:
11/28/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
11/28/23 Evening Shift 2:00 PM to 10:00 PM: Pain Level 0 signed by ADON E.
11/28/23 Night Shift 10 PM to 6:00 AM: Pain Level 0 signed by LVN H.
11/29/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
11/29/23 Evening Shift 2:00 PM to 10:00 PM: No entry
11/29/23 Night Shift 10 PM to 6:00 AM: Pain Level 7/10 signed by LVN H.
11/30/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D.
During an observation and interview on 11/30/23 at 8:15 AM, Resident #36 was in her room, in her bed, she was frowning and asked if state surveyor could check on her medications for her. She stated she had not been getting her medicine for about four days, the staff kept telling her they were waiting for the pharmacy delivery. She stated the medication was hydrocodone for her pain. Resident #36 stated her legs, knees, and feet were very painful and they were not giving her anything for it. She shook her head, motioned toward her legs and rubbed her thighs. She stated she had been complaining of pain to the staff for days and they won't do anything! Resident #36 appeared upset and asked state surveyor to please let me know what is happening because no one will tell me anything! Resident #36's roommate, Resident #22, stated she had heard Resident #36 complaining of pain for the past couple of days and confirmed the staff had been telling her they were waiting for the pharmacy. She stated she did not have any medication issues herself but was worried about her roommate.
During an observation and interview with ADON D and ADON E on 11/30/23 at 8:20 AM, ADON D confirmed she had cared for Resident #36 that week and stated the resident did not have any hydrocodone available on 11/29/23 and she had previously called NP J about it who told her she had sent the prescription to the pharmacy. She stated she called the pharmacy on 11/29/23 and was told it would be on the next delivery, but it was not. ADON D stated today is day two when asked how long she had been out of hydrocodone. ADON D stated Resident #36 was receiving scheduled doses of gabapentin and had muscle relaxers and Tylenol extra strength ordered as needed. When asked about an emergency medication kit (E-kit), ADON D stated they previously had a box and had recently been switched to a Pyxis (machine that distributes medication) and stated they were just filling it. ADON D checked a computer and stated Resident #36's last dose was 11/28/23. She stated she would call the pharmacy and check the E-kit, then walked away. ADON E was working with a medication cart and confirmed it was the cart that contained Resident #36's medications. She stated she was just coming on and did not know anything about her situation. The medication cart was checked with ADON E and she confirmed there was no hydrocodone available for her. When asked how often medications were re-ordered for residents, ADON E stated she usually reordered when a resident was down to about 15 tablets or half a card just to be safe. She stated she may order them earlier if a resident takes multiple doses per day.
On 11/30/23 at 8:28 AM, ADON D returned and stated she just checked the E-Kit and it only contained hydrocodone 5 mg and 10 mg tablets, and Resident #36 took 7.5 mg tablets. She stated she would contact the pharmacy again.
During a follow-up interview and observation with Resident #36 on 11/30/23 at 8:30 AM, she stated she had not been given anything else for pain. ADON D entered the room during the interview and asked Resident #36 if she was in pain. Resident #36 stated she was hurting bad and rated her pain 10/10. When ADON D told the resident she had muscle relaxers and Tylenol available, Resident #36 replied, You know I don't want that Tylenol, it doesn't do anything! ADON D presented her cell phone and pointed out her text messages and stated she had texted NP J on Monday (11/27/23), told her about the scheduled hydrocodone and informed her there was only one tablet left. When asked if that meant she had not received any doses since Monday, ADON D did not answer, walked away toward her office, and took a phone call. Once off the phone, ADON D stated she had called NP J again on 11/29/23 (Wednesday)and told her the medication was not available. She stated she had checked the E-Kit on 11/29/23 as well but did not inform the pain doctor there were other dose strengths available.
Interview with the DON on 11/30/23 at 9:26 AM revealed she had been just made aware of Resident #36's lack of available hydrocodone that morning. She stated she had just hung up with NP J and the Medical Director and they were getting a one-time order for hydrocodone 10 mg and pulling one from the E-kit while they get the issue resolved. She stated NP J told her she had sent the prescription to the pharmacy earlier in the week. The DON said she called the pharmacy, and they told her they had not received it. She stated the Medical Director was in the process of sending one at that time. The DON explained controlled medications, like hydrocodone, require special triplicate prescriptions. She stated they normally do not require them for refill order as the physicians will order a six-month supply. The facility has authorized agents, like herself, who can order refills. She explained, in this instance, Resident #36 did not have any more refills and required a new prescription. She stated normally either the pharmacy would have notified her, or the Charge Nurse would have notified the physician. The DON stated ADON D told her she had notified NP J prior to the medication running out.
The DON stated she knew Resident #36 had Tylenol available as well as muscle relaxers but did not know if any had been administered. She stated she would not consider Tylenol Extra Strength to be a suitable replacement for hydrocodone but Resident #36 had muscle relaxers ordered as well and she expected her pain to be managed in some form or fashion. The DON sated she did not know if Resident #36's pain had been monitored and said it should have been monitored and documented on the MAR. The DON stated she was aware the E-kit had been stocked but, unfortunately, did not have the hydrocodone 7.5 mg dose available that had been ordered for Resident #36. She stated she did not know if anyone had told NP J or the Medical Director there were alternate doses available in the E-kit. The DON stated, if a resident ran out of pain medication, she expected the nurses to check the E-kit, look for back-up medications or other PRN orders available for the resident. If the medications were not effective, she expected the nurses to notify the physician. When asked if she was aware this was a scheduled medication, she stated she was not, but her expectations would be the same.
The DON explained medication reorders were discussed in their stand-up meetings. If a nurse ordered a medication, it was written on a board and followed for three days. She was not aware of Resident #36's medication. She stated they had missed their stand-up meeting on 11/28/23 as the survey began that day so that possibly contributed. She stated there was no facility policy for medication reorders, but she expected her nurses to use their judgement and order medications three to five days ahead of time. The DON stated pain monitoring and medication administration were important because she wanted everyone to be comfortable and pain free for quality of life. She stated, My expectation is for my staff to take care of the patients and manage their pain appropriately.
The DON stated medications could be ordered any time of day. When asked about other nurses caring for Resident #36 during the last three days, the DON identified LVN G and LVN I as agency nurses and LVN H as working night shift and PRN. She stated she had the same expectations for Agency nurses as she had for facility staff. She stated, I would think they would know as nurses not to let residents go without pain medications. It is very easy to reorder medications in [the computer software]. She stated the failure was of the nurse who first ordered it to notify her and that did not happen. The DON stated they try to keep their E-kit stocked with whatever medications residents have ordered. When it was noted hydrocodone 7.5 mg was not available, they should have tried to contact the physician for an alternative.
Observation and interview with Resident #36 on 11/30/23 at 11:10 AM revealed she was resting in bed with her eyes closed and responded to voice. She stated she had received some medication and was feeling better. She stated she was grateful because I have been asking for days.
During a follow-up interview on 11/30/23 at 11:16 AM, ADON D showed her cell phone with text messages. She identified the texts as being between herself and NP J. The text was dated Monday, 11/27/23 at 1:49 PM and reflected, Hey, [Resident #36] has 2 hydrocodone 7.5-325 can you please reorder? The text response reflected, Ok. ADON D stated she called NP J again today and was told she was sending the triplicate again.
In an interview on 11/30/23 at 11:30 AM, the Administrator and Regional Operations Manager stated there was no policy regarding reordering medications. The Administrator said the medications should have been ordered and they knew the resident had missed 9 doses of regularly scheduled hydrocodone 7.5.mg. They said the nurse should have informed the ADON or DON and the emergency meds should have contained the correct dose for the resident. The Administrator said they failed to have the appropriate medications on hand, in the emergency dispenser, and the staff did not tell anyone they needed to be ordered - they said this was a concern and placed the resident in harm due to missing their pain medication. The Administrator and Regional Operations Manager stated the Regional Nurse Consultant was at home and ill.
A telephone interview with the Medical Director on 11/30/23 at 12:08 PM revealed he was Resident #36's attending physician. He stated he had been made aware of an issue with Resident #36's prescription and had just stopped by the facility and provided an order for a one-time dose of pain medication for her while the prescription was sorted out with pharmacy. He stated he was aware she had chronic pain issues which was why he had previously consulted pain management physician. He stated he had not been notified before today there was any issues with her medication availability. He stated Resident #36 had bad arthritis. He stated he had not had any issues or concerns regarding residents receiving their medications.
During an interview on 11/30/23 at 12:12 PM, the DON provided a list of all facility residents receiving pain medications. She stated she had conducted an audit of all medication carts and ensured all residents receiving pain medications had medications available.
During an interview on 11/30/23 at 12:16 PM with ADON D stated she should check pain scales when residents receive pain medications and every shift. She stated she recalled checking Resident #36 on Tuesday, 11/28/23 and she was sleeping so she coded a 0/10. She could not recall what time she checked her or if she checked her again during her shift. She did not respond when asked about coding Resident #36's pain level as a 0 on 11/29/23 and again that morning, even though we had both seen she was in pain. She stated Resident #36 received her last dose of hydrocodone on Tuesday, 11/28/23. ADON D was shown Resident #36's MAR and asked to clarify because the last dose was signed out on Monday, 11/27/23 at 7:00 PM. ADON D stated she would check her computer. She stated she contacted the pharmacy on Wednesday, 11/29/23 and was told the medication had been ordered and was enroute. She stated when it hadn't arrived at the end of her shift, she let LVN F know the medication was not there. She confirmed she did not notify the physician the medications were unavailable.
An interview on 11/30/23 at 2:09 PM with LVN H revealed he worked the 10:00 PM to 6:00 AM shift and had cared for Resident #36. He stated the day shift had reported her hydrocodone was not available. He stated he discussed the situation with Resident #36 and let her know she had PRN medications available. LVN H stated Resident #36 would sometimes sleep through her dose hydrocodone on his shift and he did not recall her complaining of pain during his shift. He stated lately she had been sleeping better since getting scheduled medications. LVN H stated, if scheduled medications were not available for administration, he would report the information on the 24-hour report, but Resident #36's information had already been documented. He stated if she had been acting like she was in pain or throwing a fit he would have called the physician. When asked about his rating of her pain as 7/10 on her MAR for his shift, LVN H stated, What they say, may or may not be what's happening. He stated he provided other means for relief such as repositioning. LVN H stated medications should be ordered 3-5 days ahead of time to ensure availability.
In a telephone interview on 11/30/23 at 5:00 PM, NP J confirmed she worked under a pain management specialist. She stated she had received a request to refill Resident #36's hydrocodone on 11/27/23 and sent the prescription to the pharmacy the same day. She stated, for some reason, the prescription did not go through. NP J stated she knew Resident #36 well and she needed her pain medication. She stated the nurses usually sent the request further ahead of time, two to three days before because the pharmacy takes a few days to fill it. She stated the nurses knew they should order it at least two to three days ahead. NP J stated she did not know when Resident #36 received her last dose but when she was told it was still unavailable, she called the pharmacy right away. She stated she did not know the script never went through. NP J stated Resident #36 had orders for [muscle relaxer] and Tylenol as well and the nurses could have administered those. She stated, if the resident was in severe pain, the nurses could have called her for an E-kit order.
Record review of Resident #36's progress notes revealed the most recent nurse's entry was dated 11/13/2023. The following entries were made after surveyor inquiry:
11/29/2023 9:14 AM: [Recorded as Late Entry on 11/30/2023 08:35] This writer spoke with pain management about the resident medication is unavailable, resident rated pain 10/10, contacted pharmacy and was told that medication has been ordered, will continue to monitor for any changes in condition. Signed by ADON D
11/30/2023 8:35 AM: This writer assessed resident this morning, pain medication has not been delivered, resident rated pain 10/10, prn was being given, called the physician and received an onetime dose for Hydrocodone 10-325, also reached out to [NP J] (pain management) but no answer yet, left message, will continue to monitor for any changes of condition. Signed by ADON D.
11/30/23 10:49 AM: Interviewed resident about pain. Resident stated that she is improved somewhat from the administration of muscle relaxer but states her pain is still a 10 in the bilateral [both sides] legs. Informed resident that we had a onetime dose of 10-325 hydrocodone for her. Administered the 10/325 hydrocodone and will re-assess pain. Signed by DON.
11/30/23 11:50 AM: Resident notes with eyes closed, easily aroused, resident denies any pain at this time level 0/10. Signed by ADON E.
Record review of resident #36's Controlled Drug Record for her hydrocodone 7.5-325 mg revealed the final entry was dated 11/27/23 and reflected the last dose was signed out on Monday, 11/27/23 at 8:00 PM. Amount Remaining reflected 0.
Record review of the facility's Policy and Procedure titled Medication Administration dated 12/2018 revealed the following:
POLICY
It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.
PROCEDURE
1. Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration .10. If a dose of regularly scheduled medication is withheld or refused, the space provided on the front of the MAR for that dosage administration is initialed and circled. The physician will be notified if medication is routinely refused.
Record review of the facility's Policy and Procedure titled Pain Management dated 12/2018 revealed the following:
POLICY It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life.
Procedure
1. Each resident's pain will be assessed using the [Pain Assessment] in the clinical software, upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is .10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures.
Record review of the facility's Policy and Procedure titled Medication-Unusual Occurrences dated 12/2017 revealed the following:
Policy: It is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Definitions: Medication Error: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's order for that medication. Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route of administration, and/or administering to the wrong resident .
Procedure: 1. Unusual occurrences may be medication errors and/or adverse drug reactions. Medication errors and adverse drug reactions shall be immediately reported to the resident's physician and the Director of Nursing .4. Licensed nurses who observe such unusual occurrences are to: a. Take whatever immediate action is necessary to protect the resident's safety and welfare. b. Report the incident immediately to the Director of Nursing. C. Make the appropriate records and notifications required above
The Administrator and Regional Operations Manager were notified on 11/30/23 at 12:51 PM that Immediate Jeopardy and Substandard Quality of Care had been identified in the area of Significant Medication Errors. The IJ Template was provided to the Administrator and DON on 11/30/23 06/08/2023 at 1:12 PM and they were informed the POR was due to HHSC by 2:30 PM on 11/30/23.
The following Plan of Removal submitted by the facility was accepted on 12/1/23 at 2:48 PM and reflected:
11/30/2023 Plan of Removal - F-760 Medication Error- Immediate Action Taken
Resident Specific
The facility failed to ensure Resident #36 received her physician-ordered pain medication, Hydrocodone 7.5 milligrams (mg), every 6 hours due to the facility failing to re-order the medication after the last dose was administered on Monday, 11/27 /23, at 7:00 PM. As of 11/30/23, the resident has missed a total of 9 doses. The resident reports having pain at a level of 10 out of 10 on the pain scale.
Physician was notified/Medical director on 11/30/2023.
Residents was immediately assessed for pain by the DON resident stated her pain was a 10/10
Alternative medication Norco 10/325mg one time dose
Resident was reassessed in 1 hour by charge nurse after alternate medication was administered resident was asleep.
Medication Error form completed.
Pharmacy called by the DON awaiting medication to arrive.
System Changes
Residents will be monitored for pain daily all negative findings will be giving to the DON/ designee.
100% Audit will be completed of all resident's pain risk to ensure all at risk residents have been identified. Audit was initiated on 11/30/2023 and will be completed on 12/1/2023 by Nurse managers.
DON/designee will monitor medication available report daily to ensure all medications are given as ordered to address any possible significant medication errors. System initiated on 11/30/2023.
Education
Regional Nurse Consultant, RNC educated DON/ADON/MDS if a resident is out of pain medication to notify the MD and DON immediately on 11/30/23.
DON/Designee will educate Nurses CMA's if a resident is out of pain medication to notify the MD and DON immediately. Initiated on 11/30/2023 and will continue until all nurse / CMA's have been educated prior to working the floor.
DON/Designee will educate staff on when to re-order medications. Initiated on 11/30/2023 and will continue until all nurse / CMA's have been educated prior to working the floor.
DON/Designee will in-service on the availability of medication in the E-kit and calling the physician for any medications not available for an alternative dose or alternate medication that is available in the E-kit not following these instructions will result in disciplinary action.
Initiated on 11/30/2023 and will continue until all nurse/CMA's have been educated prior to working the floor.
Monitoring
DON/Designee will randomly interview resident daily. Initiated on 12/1/2023 and 12/31/2023 end [sic]
Residents will have a pain risk observation completed quarterly.
Administrator and RNC will review each task overseen by DON / Designee weekly beginning 12/1/23 and will end 12/31/2023 to ensure tasks are completed. At that time further review will be conducted through the QAPI process.
Monitoring of the facility's Plan of Removal included the following:
Interview with the DON on 12/1/23 at 3:00 PM revealed in-service training was initiated on 11/30/23 and was still in progress. The training topics included identification of signs and symptoms of pain, how and when to re-order medications, and proper documentation of pain medication administration. In-service content and sign-in sheets were requested for review.
Interviews were conducted on 12/1/23 from 3:40 PM to 4:05 PM with direct care nurses including ADON E, 1 GVN, 1 RN and 2 LVNs. The staff indicated they had been in-serviced on pain management including assessments, medication administration and documentation. The staff stated they would contact the attending physician and DON immediately if any medications were unavailable and check the E-kit for availability. The staff stated medications should be re-ordered one week in advance of the last dose.
In an interview on 12/1/23 at 4:20 PM, ADON D stated she had received in-service training from the Regional Nurse Consultant. She stated medications should be re-ordered a week ahead of the last dose available. ADON D acknowledged the failure to administer scheduled medications was a medication error. She described the risks of medications errors as increased blood pressure for a resident who didn't receive their blood pressure medications and stated residents who did not receive their ordered pain medications as at risk suffering more from pain. She stated the resident's physician and DON should be notified of any medication errors.
In an interview on 12/1/23 at 4:18 PM, the DON revealed she had been in-serviced by the Regional Nurse Consultant and was still in progress in-servicing all staff. She stated medications should be ordered approximately a week in advance. The DON stated all nurses should be assessing residents for pain every shift and as needed. She explained residents should also be assessed around the administration of pain medications and treatments. She stated she was also in-servicing CNAs regarding pain assessments as well. She had instructed them to report any signs of pain to the charge nurse and to come to her if they felt the resident's pain was not managed. She stated she had begun auditing pain assessments and will continue to monitor to ensure completion. The DON stated, if medications were not available, the nurses should check the E-kit for availability. She stated she printed the inventory and placed it with the E-kit machine so that nurses could more quickly check availability. If the medication was not available, the nurse should contact the physician and the DON to obtain an order. The DON stated any medication errors were to be reported immediately to the physician and herself and monitor the resident. She stated she was responsible for investigating and documenting the errors. The DON stated all staff currently working had received their in-service training. All staff not yet trained will receive in-service prior to beginning their next shift.
During an interview on 12/1/23 at 4:50 PM, the Regional Director of Operations stated he felt all the problems identified came down to communication. He stated medication issues should start with the nurse and move up the chain. He stated he had periodically attended the facility stand-up meeting and planned to attend more regularly and monitor the situation. The Regional Director of Operations s[TRUNCATED]
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free misappropri...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to be free misappropriation of resident property for 1 of 8 residents (Resident #57) reviewed for drug diversion.
The facility failed to prevent an employee with access to controlled medications from diverting an unknown number of Tylenol #3 tablets (a Schedule III narcotic drug used to treat pain) tablets belonging to Resident #57 from a medication cart.
This failure could place residents at risk for unrelieved pain due to his medication not being readily available.
Findings included:
Record review of Resident #57's Face Sheet dated 11/29/23 revealed the resident was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including vascular dementia, unspecified open wound of the right lessor toe, non-pressure chronic wound of the right foot, pressure ulcer of other site Stage 2, pain in unspecified joint, and pain unspecified.
Record review of Resident #57's Physician's orders dated 11/30/23 revealed the following entries:
Acetaminophen-codeine tablet 100-30 mg 1 tab every 6 hours PRN. Order start date: 12/23/22, end date: 8/23/23.
Acetaminophen-codeine tablet 100-30 mg 1 tab every 6 hours PRN. Order start date: 8/24/23, end date: 11/28/23.
Acetaminophen-codeine tablet 100-30 mg 1 tab every 6 hours PRN. Order start date: 11/28/23, end date: Open Ended.
Record review of Resident #57's MAR dated 8/1/23-8/31/23 revealed the following entries:
Acetaminophen-codeine tablet 300-30 mg; Administer 1 tab every 6 hours PRN. The MAR reflected no doses were signed as administered on 8/23/23.
Acetaminophen tablet 325 mg 2 tablets every 6 hours PRN. The MAR reflected one dose was signed as administered on 8/23/23 at 8:45 PM.
An observation and interview on 11/28/23 at 12:40 PM with Resident #57 revealed he was sitting up in bed, clean and well groomed. He stated his care in the facility was good and he had no complaints. Resident #57 stated he did not have any concerns about his pain medications. He stated he heard they ran out of Tylenol a few months ago and did not understand why. Resident #57 denied missing any doses of his pain medication or having any unrelieved pain.
Record review of a facility Provider Investigation Report dated 8/24/23 revealed ADON K was accused by ADON D of taking medications from a medication cart. ADON K was also accused by LVN L of attempting to remove medications from another nurses' medication cart.
A written statement by ADON D included in the report reflected: 8/23/23
I, [ADON D], was the LVN working the floor on 2 Central today. I clocked in at 0610 (6:10AM) and came to get report from the night nurse. When I arrived on the floor, the night nurse .was gone and [ADON K] had my medication cart keys and stated she had taken over all the carts on the floor and sent the night nurse home. When I walked around the corner to get my keys from the ADON, she was in the narcotic box on my cart. I asked her what she was doing. She stated she was getting a Tylenol 3 out for [Resident #57]. After she had administered the medication to the resident, I counted the cart to take over the shift and then noticed [Resident #57's] card and count sheet were not in the count. I asked the ADON about the narcotic for [Resident #57] and why it was not on the cart anymore and she stated, He doesn't use it enough, so I am going to discontinue it and I am going to give it to [DON]. She had the narcotic medication and the count sheet in her hand and took it to her office. I then looked at the documentation
and saw that the narcotic that the [ADON K] allegedly gave to [Resident #57] was not signed off on the EMAR, but I had no sheet to verify the count. I notified the DON of the situation immediately. Later that day the ADON pulled me into her office and told me, They are looking for [Resident #57's] narcotic medication. Don't tell them l have it. I walked out of the office and immediately reported the situation to the DON. The statement was signed by ADON D and dated 8/23/23.
A written statement by LVN L included in the report reflected:
8/23/23
I, [LVN L] clocked in and went to get report. [ADON K] was at the nurses'
station and had the keys to the medication cart. She stated that the night nurse was sent home and she would be giving me report and counting with me. I counted with her and noticed that a narcotic card and sheet were missing from the shift from the previous day. I asked the ADON
where the narcotic card and sheet were. She stated that she was going to discontinue them and give them to the DON, l advised her that was not the procedure that was to be followed. I reminded her that only the DON was to receive narcotics that were to be destroyed. I requested that she put the narcotics back on the cart. She was hesitant to do so and again I asked her to put the narcotics back on the cart for the DON to pick up. She gave me back the card and sheet to give to the DON for destruction. I gave the DON narcotic card and sheet for destruction. The statement was signed by LVN L and dated 8/23/23.
A written statement by RN M included in the report reflected:
8/23/23
I, [RN M], clocked in to start my shift. When l arrived to the nurses' station, the night nurse was there. l asked her if she was ready to count the carts and she stated the ADON had counted the carts and had the keys. I then called the ADON and asked her to come count with me. She told me over the phone, 'Come get the keys'. I then walked down to the office and passed her in the hallways. She attempted to give the keys to me without counting the cart and I advised her that this is not the procedure. I then told her that she needed to count with me before I took the keys to the cart. We counted the cart and it was correct. The statement was signed by RN M and dated 8/23/23.
A written statement by the DON included in the report reflected:
8/23/23
[Resident #57] was interviewed by DON and stated that he did receive 'one white pill' this morning from the nurse for pain. He states he usually gets 'two white pills'. Resident was unable to state if this was Tylenol 325mg or a Tylenol #3. Neither medication was signed off on the EMAR by the nurse, [ADON K], who allegedly administered this medication. The statement was signed by the DON and dated 8/23/23.
No written statement from ADON K was included in the report.
The Provider Investigation Report also included the following:
Agency Immediate Response:
Interviews conducted with off-going and in-coming staff
Statements obtained from nurses
Narcotic was verified and accurate with exception of narcotics missing for [Resident #57] Resident interviewed - denies pain or distress
Regional nurse and HR notified
Accused nurse suspended until investigation completed
Nurses who worked that cart were sent for drug screening
Medication administration monitoring began
Safe surveys initiated - no Issues noted
In-Services Initiated - Abuse/Neglect, Medication administration, Narcotic Count procedures
Pharmacy consultant and director notified
Medical director notified
Resident's physician notified .
Ombudsman notified
Accused nurse terminated after Investigation
Events reviewed in stand up for potential diversion discussed daily
Narcotic count done daily by DON - no issues noted.
Investigation Summary:
Monitoring sheets were put in place to monitor medication administration 5 days a week for 4 weeks
Narcotic count sheets audited per following schedule by DON/designee (5 times a week for 2 weeks, then 2 times a week for 2 weeks, then 1
time a week for 4 weeks)
Daily monitoring of narcotic medication receipt log and delivery manifests
Ongoing education of nursing staff regarding handling of narcotic medications, discontinuing unused medications, and
Ongoing In servicing of nursing staff
Medical director notified, ombudsman notified, family notified
No negative outcomes from drug screens.
No other negative outcomes from investigation. Resident does not show any signs not symptoms of distress related to incident.
No other residents were involved in the incident. Resident does not have pain, nor S/S of distress He did not miss any medications,
Employee [ADON K] was terminated from employment.
Investigation Findings:
Agency Action Post-Investigation
Ombudsman, physician, RP/Resident, Medical director notified of outcome.
Inservices on ANE and handling of narcotic medications, discontinuing narcotic medications were initiated.
Resident does not show any signs not symptoms of distress related to incident.
An interview with the ADON D on 11/28/23 at 11:32 AM revealed she had reported Resident #57's missing Tylenol #3 medication to the DON back in August. She stated she remembered coming in that morning and ADON K told her the night nurse had already gone home and she tried to hand her the keys to her medication cart. She stated she told ADON K she was not accepting the keys until they counted the cart together. She walked away to put her things away and when she returned, ADON K was in her cart. She stated ADON K told her she had just given Resident #57 Tylenol #3. ADON D stated the thought that was odd because he rarely wanted it and was usually fine with regular Tylenol. She stated they counted the cart together and the counts were correct. ADON D stated was not an ADON at that time and was working as an LVN. She initially let ADON K take the card and count sheet because, at that time, they were allowed to turn medications over to the ADONs for destruction and she thought she recalled the physician talking about discontinuing the medications. ADON D said she checked Resident #57 who stated he may have received the Tylenol #3 but wasn't sure because the pills looked similar, and his pain was not bad that morning. ADON D stated she spoke with ADON K and asked if she had given the medication to the DON yet. She stated ADON K told her, not yet and don't tell her I have them. ADON D stated she immediately reported the occurrence to the DON. She stated the DON had asked ADON K about the meds and she denied having them. ADON D explained they typically give the DON medications for destruction, but ADON K had previously been allowed to accept them as the DON had just started working there. She stated she had never given any other meds for destruction to ADON K but did that day because she was already there. She became suspicious when she saw it wasn't signed out on the MAR, only the count sheet. ADON D could not recall how many pills were left on the card.
An interview with the DON on 11/29/23 at 9:00 AM revealed she just started working in the facility at the beginning of August 2023. She stated on August 23 she began getting calls from nursing staff around 5:45 AM asking why ADON K was taking keys from the night shift. She began quickly heading to the facility. She stated she received a call from ADON D who told her ADON K had taken a card and count sheet for Tylenol #3 for Resident #57. She stated she called ADON K and asked her about the keys but got no real explanation. She described ADON K as talking around everything. She stated ADON K was not aware she was already pulling into the facility at that time. The DON stated when she arrived, she went straight to ADON D's cart, checked it with her, then checked all the other carts. She stated she spoke with LVN L who told her ADON K had attempted to remove a card of Tylenol #3 from her cart that morning, but she would not allow it. The DON stated she wanted to give ADON K a little time to turn the meds into her for destruction. The DON stated, before her arrival that month, ADON K was performing the drug destruction for the facility so she could see why it did not initially come as a surprise to ADON D. She stated, when ADON D noticed on the MAR that Resident #57 had continued to periodically request the med and ADON K failed to sign it out, she called her right away. The DON stated she could not initially locate ADON K in the building. She checked on Resident #57 who told her he received a white pill that morning but could not tell the difference between regular Tylenol and #3. He denied being in pain. She alerted the Administrator. The DON stated when ADON K came to her office, she asked the ADON if she had any medications for destruction and was told, no. When she asked the ADON why she had taken the keys from the night staff, she replied she wanted to let them go early. When the DON told her she had never done that before, ADON K just said, 'ok'. The DON stated she contacted the Administrator and Regional Nurse consultant and explained the situation and reported ADON D's allegation that ADON K told her not to tell the DON she had the drugs. The DON stated she and the Administrator pulled ADON K into the office and confronted her. She said they told her they knew the medications were missing on her watch. The DON stated ADON K denied everything and was not acting right and she suspected the ADON was under the influence of something. The DON stated they contacted HR who took ADON K, ADON D and LVN O for a drug screen. She stated the HR representative rode with them. The DON explained LVN O was only sent because the Regional Nurse Consultant requested a random night nurse get checked as well, they had no suspicions of her.
The DON stated ADON K's drug screen returned positive for codeine, and she had no prescription for the medication. She stated ADON K was suspended immediately and ultimately terminated. They were unable to recover the medications and ADON K was not allowed to work in the facility while the investigation was under way. She stated ADON K refused to write a statement. She stated Resident #57's medications were immediately replaced and he did not miss any doses. The DON stated she believed the overall failure was they nurses were counting medications and not actual cards as well [6 inch x 9 inch cards with numbered cavities containing pills that allow the staff to punch out individual doses]. She stated a full audit had been completed and the Pharmacy Consultant was involved as well. They did not note any other medications missing during the time she was assisting with drug destructions. The DON explained she had immediately written a new procedure and in-serviced all staff. She stated she checked carts daily herself to ensure all controlled medications are accounted for. The DON did not know how many tablets were remaining on the missing card containing the acetaminophen with codeine.
During a follow-up interview on 11/29/23 at 10:50 AM, the DON stated the police had been called and notified by the Administrator, but no one ever came to investigate.
Observation and interview with RN M on 11/29/23 at 11:59 PM she stated she was aware of the drug diversion that had occurred in August. She stated she remembered clocking in that morning and seeing the night nurse at the nurses' station. She told the nurse, Let's go count as usual but was told ADON K had already counted the cart with the night shift nurse, RN M stated that was very unusual and had never happened before. She stated the night nurse told her it was because she was late and she told them she was not late, it was 6:05 AM. RN M stated she called ADON K on her cell and was told to come and get the keys from her. She stated she went to office and ADON K tried to hand her the keys. She stated she refused to accept the keys and told ADON K, you know better than that, we're going to count the meds. She stated the two of them counted the cart and everything was correct. She did not believe anything was missing because she knew her residents well and had very few controlled medications in her cart. She stated she had never given controlled medications to ADON K before and would only go to the DON if she needed to. She stated she knew they were without a DON for a bit, but she did not personally have to turn anything in for destruction during that period. RN M explained the DON had implemented a better system and they now count the number of cards as well as the individual medications. She stated she had received training and any discrepancies or questions go straight to the DON.
On 11/29/23 at 6:16 PM, attempt to reach ADON K at a number provided by the facility was unsuccessful. A voice message was left.
During an interview with the Administrator on 12/1/23 at 8:15 AM, He stated he was surprised when the drug diversion had occurred, and he had not encountered that issue before. He denied having any previous concerns with ADON K.
Record review of a facility in-service record on Controlled Medication Procedure dated 08/23/23 revealed the following:
All Nurses and Medications Aides:
We have implemented the new system for narcotics, and it is the expectation that it will be followed at all times with no exceptions. This is a VERY serious matter and any violations of the procedure will be addressed and disciplined immediately .
-
Use the new narcotic count sheet that was implemented
-
Do NOT hand your keys to the medication cart for ANY reason (BATHROOM, BREAK, ETC) without COUNTING AND
SIGNING FIRST!
-
You are to sign and count every single time you hand your keys off. NO exception.
-
NEVER LEAVE YOUR CART UNLOCKED AND UNATTENDED
-
If you discover the count is off, you are to notify the DON immediately
-
Do NOT hand your keys off if the count is not correct. STOP and notify DON.
-
Nurse/CMA that is going off shift, is NOT allowed to leave the shift until the DON arrives and narcotic count is corrected
-
AGAIN, DO NOT HAND THE KEYS OVER TO ANYONE UNTIL YOUR NARCOTICS ARE COUNTED! THIS INCLUDES THE DON/ADON/UNIT MANAGER, ETC.
-
ONLY the nurse who is caring for the resident, will discontinue narcotics after receiving an order from the physician
-
ONLY nurse will give the DON discontinued narcotics off their cart for destruction.
-
If ANYONE besides the DON takes a narcotic off your cart, notify DON immediately.
-
All narcotic medications will be signed out of the log sheet when the medication is popped or dispersed from the narcotic package. DO NOT SIGN OUT LATER.
-
All Narcotic medications will be signed out on the EMAR as administered and not AFTER administration
-
After the last space is used on the narcotic log sheet for the end of the month, the sheet will be turned into the DON and a narcotic log sheet will be started. DO NOT THROW AWAY!
-
If a narcotic is being taken off the cart and destroyed by the DON, the nurse and the DON will count the card, sign and date the count sheet AND THEN MAKE A COPY. This copy will be given to the Administrator for a back-up record.
Record review of the facility's Drug Diversion policy and procedure, dated December 2018, reflected:
POLICY
It is the policy of this home to ensure drug diversions are investigated and reported to the proper authorities, per regulation.
PROCEDURE
1. Controlled substances in Schedules II, III and IV are subject to special handling, storage, disposal and record-keeping requirements. Such drugs are to be accessible only to authorized nursing and pharmacy personnel. The Director of Nursing is responsible for the control of such drugs.
2. Drugs listed in Schedules II, III and IV are to be stored under double-lock conditions. The key to the separately locked storage area is not the same key that is used to gain access to other drugs. The medication nurse or medication aide on duty at the time will maintain possession of the key.
3. A physical inventory of these medications will be made at the change of each nursing shift. The persons performing the inventory will sign to verify that the inventory was done. All controlled substances are to be counted every shift, including any controlled substances that are in over-flow storage.
4. Any discrepancy in the inventory of a controlled substance .is to be reported to the Director of Nursing as soon as possible. The Director of Nursing is responsible for promptly investigating and making a reasonable effort to reconcile all reported discrepancies. If a discrepancy is not reconciled, the Director of Nursing is to document the details on the audit record and Incident/Accident Report in the clinical software, including the possible shift or persons responsible for the discrepancy, and the efforts made to reconcile it. If a major discrepancy or a pattern of discrepancies occurs, or there is obvious criminal activity, the Director of Nursing is to notify the administrator and the consultant pharmacist immediately.
5. The Administrator or Director of Nursing will be responsible to notify the local police and to immediately notify the appropriate state agency when it is determined or there is reason to believe that the drug diversion was a result of theft.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the tran...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for one (Resident #228) of one resident reviewed for transfer and discharge.
The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #228 was discharged on 04/10/23.
This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.
Findings included:
Record review of Resident #228's electronic face sheet, dated 11/30/23 revealed the resident was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include dermatitis, contact with COVID, muscle wasting and atrophy.
Review of Resident #228's progress notes dated 04/10/23 11:59 PM, indicated Resident #228 discharged via stretcher/ Ambulance, accompanied by sheriff. This was not a planned discharge.
Record review of Resident #228 reflected electronic communication via email dated 04/11/23 Ombudsman reflected: I am reaching out regarding the improper discharge of Resident#228 from The Meadows Health and Rehabilitation. He states he has been told that he will not be able to return to The Meadows Health and Rehabilitation after he is discharged from the hospital. He also stated the was not given proper 30-day notice of discharge. Resident #228 is intitled to a proper discharge notice if you all are involuntarily discharging him. He has also the right to return to The Meadows Health and Rehabilitation as well. Please give me a call.
During an interview on 11/30/23 at 11:06 AM, the Social Worker revealed in progress notes in the electronic medical records regarding Resident #228 was showing increased agitation with roommates and inciting violence, refused to participate with psych services on-site resulted in initiating a [NAME] Warrant-a legal process through which a person is detained or hospitalized against their will for mental health treatment. The Social Worker revealed the intention was Resident #228 would not return to this facility. The Social Worker revealed the resident was given written notice of discharge the same day as the discharge. The Social Worker revealed he had not put a copy in Resident #228's electronic medical record. The Social Worker revealed he notified Resident #228's family member. The Social Worker indicated the Ombudsman notified the Social Worker next day via email. The Social Worker revealed the ombudsman discharge notice only needed to be at time of a discharge. The Social Worker revealed the notification of the discharge for Resident #228 to the Ombudsman was done the day after resident #228 was discharged due to time of night of the discharge. The Social Worker revealed if the facility feels there was a concern for self or others well-being or increase agitation of a resident the resident will be provided the option to participate in psych services, if the resident declines psych services the facility may obtain a court order and have the resident transferred to a psych hospital via the sheriff's dept. There were no progress notes in resident #228's medical record indicating an increase in agitation.
Interview via phone with Ombudsman on 11/29/2023 revealed Ombudsman contacted the Social Worker after Resident #228 contacted her to say the facility had discharged him. Ombudsman revealed she had not been notified by the facility Social Worker and had emailed the facility Social Worker to inquire.
Record review of facility's Discharge - Transfer of the Resident policy, dated December 2017, reflected:
It is the policy of this home that residents and/or responsible parties will be notified prior to transfer or discharge. discharged residents will have documentation related to discharge or transfer in clinical software.
Record review of facility's Behavior Management-Crisis policy, dated December 2017, reflected:
It is the policy of this home to identify and manage residents in a safe and caring manner when they are experiencing a behavior crisis. Including the following procedures
1.
Implement measures to ensure safety.
2.
Summon additional staff needed.
3.
Diffuse crisis through calming communication
4.
Assess need for additional intervention.
Remove resident from situation.
Remove offending stimuli from resident.
Place resident in safe environment
Remove onlookers from the area.
5.
Contact administrator/designee and family/responsible party.
6.
Contact physician.
7.
Contact local police if behavior crisis requires immediate removal from home.
8.
Document, in the clinical software, the crisis including description of incident, resident's perception, interventions, outcomes and steps taken to prevent reoccurrence.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one (Residents #15) of two residents reviewed for personal care.
The facility failed to provide personal care and skin care for Resident #15 by not trimming his fingernails.
This failure could place residents who require staff assistance at risk of dermatitis, infections, and low self-esteem.
Findings included:
Record review of Resident #15's face sheet, dated 05/18/21, reflected Resident #15 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #15 had diagnoses of Other cerebrovascular disease ( group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body ), unspecified affecting unspecified side, muscle wasting and atrophy( body tissue or an organ waste away), neuromuscular dysfunction(a wide-range of diseases affecting the peripheral nervous system,) site not specified, Contracture of muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), multiple sites, Other reduced mobility, Diabetes mellitus due to underlying condition with diabetic nephropathy (Damage to kidneys caused by diabetes).
Record review of Resident #15's [NAME] MDS assessment, dated 10/20/23, reflected he had a blank BIMS which indicted he was severe cognitively impaired. Resident #15 was dependent on staff to complete ADLs of bed mobility, dressing, and personal hygiene.
Record review of Resident #15's Comprehensive Care Plan, dated 10/27/23, reflected the following: ADLs functional Status/rehabilitation Potential task- Goal The resident will maintain current level of function. Approach: Check nail length and trim and clean on bath day and as necessary
In an observation on 11/30/23 at 3:07 PM, Resident#15 had fresh, red, scratch marks on the right side of his face. Observed on both hands that all nails needed to be trimmed. The nails on both hands were approximately 0.3cm in length extending from the tip of his fingers.
In an interview on 11/30/23 at 3:10 PM with RN M revealed Resident#15 nails were supposed to be trimmed when the resident was given a bath by the nurse.
In an interview on 11/30/23 at 3:15 PM with RN C revealed the residents nails were supposed to be trimmed by the doctor. RN C revealed she had never trimmed Resident #15 nails.
In an interview on 11/30/23 at 4:11 PM with the DON revealed Resident#15 was a diabetic and could only have his nails trimmed by the doctor or nurses. The DON revealed that the CNA's could trim the non- diabetic residents' nails. The DON revealed residents' nails needed to stay trimmed for infection control purposes. The DON revealed all nurses are responsible for the care of the residents staff.
The ADL policy was requested on 11/30/23 at 4:11 PM to the DON. The facility did not provide a policy for ADL Care at the time of exit
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement measures to prevent further decrease in ROM ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement measures to prevent further decrease in ROM for 2 of 10 residents (Residents #15 and #21) reviewed for contractures.
The facility did not apply a splint on Resident #15's and Resident#21's hands to prevent a decline in ROM.
This failure could place residents at risk for further decline in ROM and development of contractures.
Findings included:
1. Record review of Resident #15's quarterly MDS assessment dated , 10/20/23, reflected Resident #15 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #15 had diagnoses of Other cerebrovascular disease ( group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body ), unspecified affecting unspecified side, muscle wasting and atrophy( body tissue or an organ) waste away,), neuromuscular dysfunction(a wide-range of diseases affecting the peripheral nervous system,) site not specified, Contracture of muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), multiple sites, Other reduced mobility, Diabetes mellitus due to underlying condition with diabetic nephropathy (Damage to kidneys caused by diabetes).
Record review of Resident #15's Comprehensive Care Plan, dated 10/27/23, reflected the following: Restorative nursing- Resident has contracture to left upper extremity. Wears splint. Goal: Resident will not experience worsening of contracture to left upper extremity. Approach: Pt may use Left elbow extension splint and Left wrist brace/support for contracture preventions tolerated. Twice A Day; 07:00, 19:00.
Record review of Resident #15 physician order's reflected, Place splint to left hand wrist daily as tolerated on 04/05/22.
In an observation on 11/28/23 at 2:30 PM Resident#15's left hand was balled up and did not have on a splint.
In an interview on 11/29/23 at 2:37 PM, the ADON revealed she would find out why Resident#15 was not wearing his splint.
In an observation on 11/29/23 at 2:40 PM, the ADON searched Resident #15's room for splint. The splint was not found in Resident #15's room.
In an interview on 11/29/23 at 03:30 PM with the DON revealed orders were placed under general and not nurses TAR. The DON revealed the nurses who took the order were responsible for putting the order in The DON revealed, that the ADON, nurses and herself are responsible for checking physician orders to prevent resident not receiving their ordered care. The DON revealed if the residents were not wearing their splint the contractures could worsen and pain. The DON revealed Resident #15 contractures had not gotten worse.
In an interview on 11/30/23 at 10:49 AM, the DOR revealed therapy did assessment and consulted on 07/11/23 to determine if the splint was needed. Resident #15 was discharged from occupational therpay on 08/15/23. The DOR revealed after the resident was discharged , it was up to the nurses to continue with splint order. The DOR revealed the splint is used to protect from contractures getting worse, getting indication on the skin and pain .
2. Record review of Resident #21's quarterly MDS assessment dated , 10/21/23 reflected Resident #21 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #21 had diagnoses of Unspecified dementia, unspecified severity, muscle wasting and atrophy, multiple sites, Contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity), other specified joint, anxiety disorder due to known physiological condition, Epileptic seizures related to external causes, and brain injury.
Record review of Resident #21's Comprehensive Care Plan, dated 10/26/23, reflected no documentation of splint.
Record review of Resident #21 physician order reflected, Please apply splint to left hand daily as tolerated .07:00 on 06/03/22.
In an observation on 11/29/23 at 2:40 PM,Resident #21 was not wearing the splint and his left hand was balled up. Observed the ADON search Resident #21's room for the splint. The splint was not found in Resident #21's room.
In an interview on 11/30/23 at 10:49 AM, the DOR revealed therapy did assessment and consulted on 01/27/23 to determine if the splint was needed. Resident #21 was discharged from Occupational Therapy on 02/28/2023. The DOR revealed after the resident was discharged , it was up to the nurses to continue with the splint order. The DOR revealed the splint was used to protect contractures getting worse, getting indication on the skin and pain.
Record review of the facility's Range of Motion Exercises policy, dated December 2017, reflected: It is the policy of this home to provide range of motion for residents in order: .7. To prevent contractures from becoming worse if they are already present
ADON D did not respond back by exit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for two of two rooms (storage room and shower room) in ...
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Based on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for two of two rooms (storage room and shower room) in the facility's secured unit, reviewed for accidents and hazards.
The facility failed to ensure the storage room and shower room doors, in the secured unit were locked.
These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products.
Findings included:
Observation on 11/28/23 at 11:34 AM in the secured unit revealed the storage room door in the secured unit was unlocked. The door had two locks, a dead bold and a regular lock on the doorknob. Both were unlocked. The storage room contained oxygen condensers and bottles,, deodorants and wound care supplies including wound spray labeled, Keep out of reach of children. Shampoo and conditioner, shoes, a fan, fall mats, hand sanitizer, and alcohol pads were also in the room. The room was observed to be clustered with these items which made it difficult to move in the room.
Observation on 11/28/23 at 12:23 PM revealed the door to the shower room was unlocked. Inside the shower room a cabinet containing personal care items was also unlocked with the unpadlocked hanging on the door. Shampoo, body spray, and lotion were in the shower area of the shower room. A stick deodorant and shave cream, both with labeling that stated, Keep out of reach of children, was also in the shower area. A sharps container containing an overfilled sharps bin attached to the wall in the shower room. The lid on the bin did not close completely due to used razors inside the bin blocking the closing mechanism.
In an interview on 11/28/23 at 12:40 PM, CNA B stated none of the residents in the secured unit wandered in and out of rooms but both doors should be locked to ensure the safety of the residents in the secured unit. She said she believed the nurse had the keys to the doors but the locks on both the storage room door and the shower room door did not work. She said the unlocked doors could be a hazard for residents if they did get into the rooms. She said residents could get into personal care products and ingest them accidentally. She said the sharps bin should be changed because it was full and did not close properly. She said she was not sure where the key to the container was but would ask the nurse. She said she had not told maintenance about the broken locks but knew she should log maintenance concerns in the logbook at the nurse's station.
In an interview and observation on 11/28/23 at 12:50 PM, RN C stated the supply closet should be kept locked because there were items in the room that could ham the residents. She said the clutter alone could make anyone fall in the room. She said she did not know why the room was not locked and tried to lock it with keys from her key ring. She said none of her keys worked on the storage room door lock and one of the locks were broken. She went to the shower room and said the sharps bin should be changed because it was filled with used razors. She said the Shower Room door should be locked to ensure the safety of residents. She said personal care items should be secured in the cabinet in the shower room and also locked. She said she did not know why they were not locked but she expected the Shower room to be secured. She pointed out that the lock on the shower room was broken did not allow the door to close properly. She said she did not know it was broken and needed to be logged in the maintenance logbook at the nurses' stations. She said she expected CNAs to let her know when things were broken or needed repair so she could follow up with maintenance. She said although the residents in the secured unit did not have a history of wandering into rooms, the unlocked doors posed a risk of accidents to the residents because they did have access to the shower room and storage room. She called the Maintenance Director to repair the locks.
In an interview on 11/29/23 at 11:50 PM, the Maintenance Director said he was called to the secured unit yesterday to repair broken locks on the storage room and shower room doors. He said he was not aware the locks were broken. He said he completed the repairs on 11/28/2023 and both doors were secured now. He said nursing staff were expected to log any maintenance issues in the Maintenance Logbook at the nurses' station. He said he checked the logs daily and made weekly door rounds to check them for security but said he had not checked the shower room door or the storage room doors, in the secured unit, recently.
In an interview on 11/29/23 at 11:50 PM, the Administrator stated upon learning of the unsecured storage room and shower room doors, in the secured unit, he had the Maintenance Director repair them immediately. He said the repairs were completed on 11/28/2023 when RN C was made aware that they were not secured. He said he recognized the importance of the doors being locked as there were items in both the shower room and the storage rooms that could pose a risk of harm to residents. He said the facility did not have a policy related to accidents or hazards, but he said he expected all staff to record any maintenance issue in the logbooks at the nurses' stations and to notify both the DON and him of the issue.
In an interview on 11/30/23 at 9:49 AM, the DON stated she had been made aware the doors to the storage room and shower room, in the secured unit, were not locked on 11/28/2023. She said maintenance repaired the locks the same day. She said there was no history of residents wandering from room to room and most of the residents had mid-range BIMs Scores (mild cognition impairments). She said the doors still needed to be secured to ensure the safety of the residents and minimize any possibility of accident or hazard. She said the facility did not have a policy directing accident and hazards but expected all staff to ensure resident safety. She said it was her and the Administrator's roll to train staff on resident safety and minimizing accidents and hazards.
In an interview on 12/01/23 at 4:40 PM the COO stated he was not sure why the facility did not have a policy directing procedures to minimize accidents and hazards. He said he expected the Administrator and DON to train staff on safety procedures and resident safety in the Secured Unit.
Record review of the maintenance logbook dated 07/12/23, through 11/28/23, at the nurses' station, reflected no documentation of broken locks on the shower room or storage room doors in the secured unit.
Record review of the facility's, Call light and door check log, dated 11/2/23-11/27/23 reflected no documentation of checks on the Secured Unit's indication storage room or shower room doors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care.
The facility failed to perform routine bi-pap (bilevel positive airway pressure is a machine that helps you breathe) maintenance.
This failure has the potential to affect residents who use bi-pap machines in the facility.
Findings included:
Resident #40 Face Sheet Record Review revealed the resident was a [AGE] year-old male admitted [DATE]. Resident#40 face sheet revealed a BIMS score of 14 indicating the resident was cognitively intact.
Resident #40's MDS revealed a diagnosis of Arthritis and Alzheimer's disease.
Observation of resident in resident's room on 11/28/23 at 12:04 PM revealed a yellow sediment in the bottom of the water reserve of the ci-pap/bi-pap machine on the resident's bedside table. Revealed no date on the ci-pap/bi-pap tube. The bi-pap tube had tape wrapped around the tube in various places.
Interview on 11/29/23 at 02:45 PM with nurse LVN F revealed the resident is on a bipap that connects to his oxygen that he uses at 2300 or when he goes to bed. LVN F revealed the bipap was cleaned weekly at 11pm and the tubing changed weekly. LVN F indicated if the bipap is dirty it would be cleaned as needed.
Resident #40's Care Plan dated 06/06/23 reflected the resident refused use of the bipap.
Electronic medical records reflect order that began on 05/12/23 for c-pap/bi-pap nightly per preset settings starting at 11:00 PM daily for diagnosis of chronic obstructive pulmonary disease.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to provide a private space for residents' monthly council meetings for 08 of 08 residents (Residents #14, #17, #18, #24, #25, #41, #42 and #50) ...
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Based on observation and interview, the facility failed to provide a private space for residents' monthly council meetings for 08 of 08 residents (Residents #14, #17, #18, #24, #25, #41, #42 and #50) reviewed for resident council.
The facility did not provide a private space for resident council meetings for Residents #14, #17, #18, #24, #25, #41, #42 and #50
This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.
Findings included:
In an interview and observation on11/29/23 at 11:00 AM, the Activity Director stated resident council was held in the downstairs dining area monthly. The Activity Director said there was not a private area in the facility for the Resident Council to meet. The Activity Director placed three wet floor signs in the entrance way to dining hall. The Activity Director stated the signs were placed to prevent staff and visitors from walking into the meeting.
In an observation on 11/29/23 at 11:03 AM, a Resident Council Meeting was conducted with Residents #14, #17, #18, #24, #25, #41, #42 and #50 were in attendance. The meeting was being held in the open dining room, near the elevator and kitchen. There were no doors that could be closed to ensure the residents' privacy during the meeting. Staff were observed in the area. Interview with Resident #24 and Resident #41 stated they did not care where the meetings were held.
In an interview on 11/29/23 at 11:43 AM, the Administrator said the facility had no other place big enough for the Resident Council to meet. Administrator stated the front conference room was occupied with meetings. The Administrator stated staff and resident frequently go to the front and would interrupt.
Record review of the facility's Resident Council Meetings policy, (undated) the facility is responsible for providing an adequate space that residents may gather in confidence.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable envi...
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Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #68) observed for infection control.
1. The facility failed to ensure clean linen closets were kept sanitary.
2. ADON D failed to complete hand hygiene while providing wound care to Resident #68
These failures could place residents at risk of cross-contamination resulting in infections.
Findings included:
1. An observation of the Clean Linen Closet in the Secured Unit, on 11/28/23 at 11:48 AM revealed a pair of white running shoes on the bottom shelf, resting on top of clean linen.
In an interview on 11/28/23 at 12:23 PM, CNA B said the clean linen closet should only contain clean linen. She stated she did not know why running shoes were in the closet. She said the laundry staff stocked the closet and all staff were responsible to ensure the closet was kept clean to prevent cross-contamination.
In an interview on 11/30/23 at 9:49 AM, the DON stated she expected laundry staff to ensure only clean linens were in the Clean Linen Closets. She said running shoes on the shelf along with clean linens posed a potential risk of cross-contamination.
In an interview on 12/1/23 at 2:41 PM, the Housekeeping/Laundry Supervisor stated only clean linens should be kept in the Clean Linen Closets. He said the shoes were likely sent to laundry and returned to the Unit cleaned and placed in the linen closet. He said they should be returned to the resident's room. He said the shoes in the Clean Linen Closet posed a risk of cross contamination. He stated laundry staff stocked clean linen in the closet. He said he had done verbal in-services on handling linens but did not have a record of the time or date.
Record review of the facility's undated Laundry and Linen Storage Policy, policy reflected: Clean laundry must be handled in such a way that contamination is avoided during transport and storage. Clean linen should always be stored in a clean, dry designated area, preferably in a purpose-built cupboard. It is the responsibility of the person disposing of the linen to ensure it is segregated properly.
2. Review of Resident #68's face sheet dated 11/30/2023 reflected the resident had the following diagnoses, pressure ulcer of unspecified heel Stage 4, pressure ulcer of right heel Stage 4, chronic kidney disease, Stage 4 (severe), lack of coordination and muscle weakness (generalized).
Review of Resident #68's care plan revised on 11/09/2023 reflected, Problem: Resident is at risk for pressure ulcer due to limited mobility 08/29/2023, resident has a stage 4 pressure ulcer on the right lateral ankle due to limited mobility. Resolved on 10/26/23. 10/19/23, [Resident #68] was seen by the podiatrist for in grown toenail, new ABT ordered for treatment. 10/05/23 Resident has stage 4 pressure ulcer on the left lateral ankle, and left medial ankle, stage 4 wound on the left medial foot. 10/26/23
Observation on 11/29/23 at 11:38 AM with ADON D revealed her completing wound care on Resident #68. ADON D completed hand hygiene and gloved. Resident #68 was in bed and ADON D positioned the resident and took off the resident's boot on the left foot. ADON D then took off the dressings on the left foot which had two wounds to the left media ankle. ADON D then cleaned both wounds at the same time with the same gloves. After cleaning the wounds there was no form of hand hygiene or change of gloves. ADON D proceeded and squeezed some Santyl ointment to gloved finger and applied to the left media ankle wound and then applied the xeroform petrolatum dressing and then dry dressing. With the same gloves, ADON D proceeded to apply the clean dressing to the left medial ankle by applying the collagen sheet and xeroform petrolatum dressing then applied the dry dressing.
In an interview on 11/29/23 at 12:05 PM, ADON D stated she was the Infection Preventionist. ADON D stated she was supposed to clean hands before and after care. She stated she did not use the hand sanitizer or wash hands after cleaning the resident's wound because she had changed her gloves, (she was not observed changing gloves during the care). ADON D was made aware she was not observed change gloves. ADON D stated there was no need to complete hand hygiene or wash hand hands after cleaning the resident's wounds so long as she changed gloves. The staff stated the facility policy also did not indicate the staff was supposed to wash hands in-between care or if someone changed gloves.
Interview on 11/29/23 at 3:05 PM with ADON D, she stated she talked with the DON and the DON informed her she was supposed to use the hand sanitizer and change gloves during wound care after cleaning the resident's wound to prevent the spread of infection.
In an interview on 11/30/23 at 11:33 AM with the DON, she stated she expected ADON D to complete hand hygiene before care, after taking off the dirty dressing and cleaning the wound and when applying the clean dressing. The staff was to complete hand hygiene and change gloves to prevent Infection control. The DON stated the ADON was to change gloves and complete hand hygiene after cleaning the resident's wound. The DON stated in-service on infection control was completed on 11/25/23. The DON stated she completed observation with ADON D on wound care, but she did not have a check-off on wound care.
Review of the facility's Hand Washing policy, revised December 2017 reflected:
POLICY
It is the policy of this home that hand hygiene is the primary means to prevent the spread of infection.
Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily available and convenient for staff use to encourage the compliance with hand hygiene.
PROCEDURE
Washing hands:
1.
The use of gloves does not replace proper hand washing. The following equipment and supplies will be necessary when performing this procedure:
a.
Running water;
b.
Soap (liquid or bar, anti-microbial or non-antimicrobial);
c.
Paper towels;
d.
Trash can;
e.
Lotion; and
f.
Alcohol-based hand rub containing 60-95% ethanol or isopropanol.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0813
(Tag F0813)
Minor procedural issue · This affected most or all residents
Based on interviews and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, ha...
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Based on interviews and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 facility, in that:
The facility did not have a policy regarding use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.
This failure could place residents at the facility who received food from outside sources at risk for foodborne illnesses.
The findings were:
Record review of an email received on 11/29/2023 at 1:24 PM from the ADM stated, The facility does not have a policy on foods brought in by visitors.
Interview on 11/29/2023 at 2:20 PM with the Dietary Manager, requested the facility's policy for foods brought into the facility by visitors. The Dietary Manager was advised that the ADM stated that the facility did not have a policy. The Dietary Manager stated that that he has been at the facility for 2 months and he was unsure if the facility had the requested policy. The DM stated that he would speak with his Dietician and his Corporate Office to try to obtain more information.
Interview on 11/30/2023 at 10:50 AM with the ADON stated she was unaware that the facility had a policy for food brought into the facility from visitors. The ADON stated she was unaware that the facility provided any form of education or training to the residents and/or visitors regarding brought into the community from outside sources. The ADON stated she has observed several residents bring outside food into the facility.
Record Review of an email sent by the ADM on 11/30/2023 at 4:45 PM included an attachment with a Policy Outside Food and Special Events dated 12/05/2019. The policy indicated residents have the right to participate in events and consume foods brought into the community from outside sources. The community will provide the resident and family education on the basics of food safety and the use and storage of food to ensure safe consumption. If the resident chooses to consume a food or beverage that is not within the guidelines of the physician's order, education will be provided, and the food will be served in the safest manner possible that can be agreed upon by the resident.
Interview on 11/30/2023 at 5:00 PM with the ADM stated that there should be some documentation in relation to the training and would provide the documentation.
The facility failed to provide documentation of the education to by residents, families, and visitors regarding outside food being brought into the facility prior to exit.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member ...
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Based on observation, interview, and record review, the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two residents of seven residents (Residents #1 & #2) reviewed for environment.
The facility failed to ensure Residents #1 & #2 had a working call light.
This failure could place residents at risk of not being able to get staff assistance when they needed it.
Findings included:
An observation and interview on 04/20/23 at 11:39 AM revealed Resident #1 pressed her call light and there was no light on the call light indicator on the resident's room or outside Resident #1's room. Resident #1 stated she used her call light for her assistance, and she was not sure how long it has not been working. Resident #1 stated she had to scream out for help.
An observation and interview on 04/20/23 at 11:40 AM, CNA A pressed Resident #1's call light, re- entered Resident #1's room and verified that Resident #1's call light was not working. CNA stated she had worked at the facility for 23 years and she did not know Resident #1's call light was not working. Then, CNA A stated she would contact the maintenance to check and fix the call light. CNA A stated the residents would not get help and delay in providing care when the call light system was not working properly.
An observation and interview on 04/20/23 at 12:24 PM revealed Resident #2 pressed her call light, and it was observed the call light was not working. Resident #2 stated she was not aware of her call light was not working and she used her call light for her assistance.
An observation and interview on 04/20/23 at 12:25 PM with Med Aide B pressed Resident #2's call light and verified that it was not working properly. Med Aide B stated she had worked at the facility for 7 years and she did not know Resident #2's call light was not working properly and stated she would notify the maintenance to fix it. Med Aide B stated the call light system was very important for all residents to get assistance from the staff. She stated she checked the call light sometimes and the residents also reported it.
An interview with the DON on 04/20/23 at 2:57 PM revealed she had worked at the facility for six months. The DON stated she expected all staff members to check the residents' call light. She stated she expected all staff members to write work order and notified the maintenance to check as soon as possible. The DON stated she was not aware of Residents #1 & #2's call lights were not working properly after verifying by CNA A and Med Aide B. The DON stated she initiated to all staff members to check the call light system and the maintenance personnel had been checking all rooms and fix them. The DON stated the residents would get delay on helping when their call lights were not working properly.
A telephone interview with the Maintenance Director on 04/20/23 at 3:47 PM revealed he did not receive report to fix the call lights for Residents #1 & #2 until surveyor intervention on the morning of 04/20/23. He stated he checked all call lights weekly , however, he had not completed checking for this week. He stated he had already fixed Residents #1 & #2's call lights and had been checking for all call lights.
Record review of the facility's policy, Answering the Call Light, dated March 2021, reflected:
The purpose of this procedure is to ensure timely responses to the resident's requests and needs.
General Guidelines
.
4. Be sure that the call light is plugged in and functioning at all times.
.
7. Report all defective call lights to the nurse supervisor promptly.
Sept 2022
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive ca...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plan to reflect the resident's current status, for 1 of 6 residents (Resident #68) reviewed for care plans.
The facility did not update Resident #68's care plan to reflect specific instructions for his medication pass.
This failure could place residents at risk for not receiving appropriate care and intervention to meet their current needs.
The findings were:
Review of Resident #68's MDS (minimum data set) assessment dated [DATE], reflected he was a [AGE] year-old male admitted on [DATE]. His diagnoses included non-Alzheimer's dementia and seizure disorder. His cognitive status was moderately impaired. He had no behaviors listed.
Record review of Resident #68's Care Plan initiated on 06/01/22 for Behavioral Symptoms reflected: Problem: The resident has potential to demonstrate verbal aggression behaviors r/t [related to] anger and inappropriate response to situations. He will raise his voice and holler and wave his arms and make fists appearing he will hit but does not. Especially if his routine is disturbed .6/15/22 Resident refused to sign consent for Depakote . Med not started. There was not a care plan to reflect specific instructions for medication pass.
Record review of Resident #68's progress notes reflected:
05/06/22 2:46 PM Patient was very upset that the med aide would not leave his medication at his bedside and patient was yelling and hitting the walls and punching his door to his room with a closed fist. The nurse tried to redirect the situation and the resident ran upon this nurse and grabbed the medication cup out of my hand. The interim DON was able to hear what was happening this nurse had her on the speaker phone while the patient was being aggressive with the staff. - LVN A
05/25/22 4:52 PM Resident came to this writer upset that he asked the nurse last night to give him Topamax at 11:00 PM, but the nurse refused. Resident is currently taking Topamax 100mg by mouth twice a day at 7:00 AM and 7:00 PM. Nurse Practitioner was informed. Received order to change Topamax to 11:00 AM and 11:00 PM. Resident was educated that staff will give him meds at the time it is ordered. Resident voiced understanding. - RN B
06/14/22 1:31 PM Resident saw Psychiatrist. New order for Depakote 125 mg two times daily. Resident was informed of new order. Order sent to pharmacy. - RN B
06/15/22 11:34 AM Resident refused to sign consent for Depakote. Med usage, and side effects explained to him, and he still refused to sign the consent. Doctor was informed. - RN B
09/27/22 12:10 PM Medication aide went into the room to give resident his AM medications. Resident wanted her to leave meds in the room. Med aide refused to leave med in the room. Resident started yelling at her and took the meds from the med aide. Med aide stayed outside the room to make sure resident took meds. RN B then went to room to calm resident down. Resident then said that he took all meds. FNP informed. - RN B
09/28/22 10:30 AM Resident noted to have combative behaviors directed toward staff this morning during medication pass. Family Nurse Practitioner made aware and orders given for 911 to be called and patient placed on 1:1 for safety of himself and others. - ADON
9/28/22 11:29 AM Medication aide went into the room to give resident his am meds. Resident wanted her to leave meds in the room. Med aide refused to leave meds in the room. Resident started yelling at her, came out of the room and chased medication aide down the hall while yelling. This writer then informed resident that behavior is not appropriate as medication aide was just doing her job. Resident then went back to his room. This writer followed resident, and resident took all his medications. FNP was informed of behavior. Family Nurse Practitionerordered that resident be sent out to hospital. 911 was called. EMS came and resident refused to go to hospital. ADON informed. Resident is calm at this time. - RN B
09/28/22 12:51 PM Resident noted to be a potential danger to himself or others. Resident continues to be on 1:1; EMS recalled; resident to be sent to ER for further evaluation. - ADON
09/28/22 1:02 PM Resident is sitting on the chair in his room at this time. Calm. On the phone. Resident was informed of need to do complete skin assessment. Resident agreed. Complete skin assessment done. No bruises, cuts or any skin issues noted at this time. - RN B
09/28/22 1:29 PM Addendum: Resident was hitting the wall during behavior. - RN B
09/28/22 14:42 Resident agreed to be transported to hospital for psychiatric evaluation. Transported by facility van. Physician notified. Resident left facility at 2:35pm. RN B accompanied patient. - ADON
An observation on 09/27/22 at 11:00 AM during initial tour revealed Resident #68 was screaming, ran into the hall, continued to scream and was chasing the ADON and Regional Nurse out of the room. Both staff walked away quickly. Resident #68 continued to be very aggressive to staff who stepped into redirect him (4 staff). The staff were able to talk Resident #68 in to going back to his room. During incident, Resident #7 was in the hallway sitting in her wheelchair. She was close to Resident #68. Resident #68 did not approach Resident #7.
An observation of medication pass on 09/28/22 at 9:54 AM with MA C revealed she prepared her medications and said she had to take medications to Resident #68. MA C knocked on his door, introduced herself and entered the room. The Surveyor stayed outside of the resident's room. Resident #68 instructed MA C to leave the medication on the table. MA C refused to leave the medications in the resident's room. MA C exited the room, Resident #68 ran out of his room, yelling and cursing at MA C. MA C was standing behind the medication cart and Resident #68 pushed the medication cart out of the way reaching for MA C. MA C tried to redirect Resident #68 without success. Resident became more aggressive and started screaming louder. Resident #68 chased MA C down the hall and MA C went into a resident's room and shut the door. Resident #68 began to punch the wall in the hall next his door. RN B attempted to re-direct him, without success. Resident #68 chased MA C down the hall again and MA C ran into another resident's room and shut the door. RN B continued to try and redirect Resident #68. The Surveyor intervened and asked the staff at the desk to please call the ADON due to safety concerns for staff and potentially other residents in the hall who might enter the hall as Resident #68 continued to chase MA C.
An interview on 09/28/22 at 10:15 am with the ADON revealed she was aware of Resident #68's behavioral incident on 09/27/22, but not the one on 09/28/22. The ADON said she would speak to the Administrator and told the nurse to call the physician. The ADON said they would collect a urine sample to see if he had a urinary tract infection .
An interview on 09/28/22 at 11:24 AM with MA C revealed the Regional Nurse interrupted the interview. The Regional Nurse said the MA C disturbed Resident #68's routine and went to his room to give him his medications instead of letting the resident come to the MA C at 11:00 AM to get his medication . The Regional Nurse said staff were only supposed to enter the resident's room in the morning time to give him his breakfast tray and then pick up his breakfast tray. The Regional Nurse was asked by the Surveyor what staff were supposed to do when Resident #68 chased them, and the Regional Nurse said they were writing a care plan for him to come out of his room to get his medications from the staff. The Regional Nurse then left the conversation. The interview continued with MA C. MA C said she did not know what she was supposed to do other than to run into a resident's room to get away from Resident #68. She said she was not aware that he had a routine that was supposed to be followed for him to go to the staff to get his medications at 11:00 AM. MA C said she also passed medications to him on 09/27/22 during that behavioral incident. She said she received no instruction on how to deal with his aggression.
An interview on 09/28/22 starting at 11:34 AM with RN B revealed the Regional Nurse was also present for the interview. RN B said staff were supposed to walk into another resident's room if Resident #68 became aggressive. RN B said his medication time was 11:00 AM and staff were supposed to wait for the resident to come to them to give his medication. She said she had told MA C to wait until the resident woke up to give him his medication. RN B said that the decision was made to give him his medications at 11:00 AM and 11:00 PM prior to the last two DONs. She said currently the facility did not have a DON. RN B said the resident had the behaviors during medication pass on and off for the past few months. RN B said he did not have a care planned intervention to get his medications at 11:00 AM. RN B said the only time the resident had aggression was during medication pass . RN B said Resident #68 posed a risk to other residents in the hall, but the resident had never hit another resident. RN B said staff needed to read his care plan and understand him to provide care to him. The interview continued with the Regional Nurse who said MA C passed medication to the resident on 09/27/22, but that time she left the medication in his room. The Regional Nurse said she and the ADON went into Resident #68's to get the medications back from him and he chased both of them out of the room.
An interview with Resident #68 on 09/28/22 at 12:40 PM revealed he had a sitter sitting outside of his room who said the resident was calm. The Surveyor knocked on the door, announced self, went in, and introduced self. Resident #68 said he was doing well. He was calm and talking on the phone. He had his lunch tray next to him.
An interview on 09/28/22 at 2:10 PM with the ADON and Regional Nurse revealed they were both new to the facility. The ADON had been at the facility for 3 weeks and the Regional Nurse had only been to the facility a couple of times. They said neither one of them were aware of Resident #68's behaviors during medication pass and that staff were supposed to know how to care for him by pulling up his care plan.
An interview on 09/29/22 at 10:46 AM with the MDS Nurse revealed she updated and initiated care plans. She said she was not aware of Resident #68's behaviors. She said if the care plan was not updated then staff would not be aware of the issue.
An interview on 09/29/22 at 11:39 AM with the Administrator revealed Resident #68 was sent to the hospital for a psychiatric evaluation on 09/28/22. He said the MDS Nurse and nursing staff were responsible for updating the care plans .
An interview on 09/29/22 at 1:17 PM with the ADON and Regional Nurse revealed floor nurses did not update care plans.
A record review of the Facility's Policy, Care Plan - Resident, dated December 2018, reflected:
Policy: It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. 6. Approach/Plan c. Individualize care to ensure the care plan is person centered for the unique needs of the resident. d. Communicate vital information to staff providing direct resident care. 7. Involved Service or Responsible Discipline. a. The following persons are to be involved in the development of the care plan: licensed nurses (LVN/RN) .12. c. The resident care plan must be kept current at all times.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), 2 harm violation(s), $35,731 in fines, Payment denial on record. Review inspection reports carefully.
- • 25 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $35,731 in fines. Higher than 94% of Texas facilities, suggesting repeated compliance issues.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is The Meadows Center's CMS Rating?
CMS assigns THE MEADOWS HEALTH AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Texas, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is The Meadows Center Staffed?
CMS rates THE MEADOWS HEALTH AND REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 56%, which is 10 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 75%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at The Meadows Center?
State health inspectors documented 25 deficiencies at THE MEADOWS HEALTH AND REHABILITATION CENTER during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 19 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates The Meadows Center?
THE MEADOWS HEALTH AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SUMMIT LTC, a chain that manages multiple nursing homes. With 184 certified beds and approximately 81 residents (about 44% occupancy), it is a mid-sized facility located in DALLAS, Texas.
How Does The Meadows Center Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, THE MEADOWS HEALTH AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 2.8, staff turnover (56%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting The Meadows Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, the facility's high staff turnover rate, and the below-average staffing rating.
Is The Meadows Center Safe?
Based on CMS inspection data, THE MEADOWS HEALTH AND REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Meadows Center Stick Around?
Staff turnover at THE MEADOWS HEALTH AND REHABILITATION CENTER is high. At 56%, the facility is 10 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 75%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was The Meadows Center Ever Fined?
THE MEADOWS HEALTH AND REHABILITATION CENTER has been fined $35,731 across 2 penalty actions. The Texas average is $33,436. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Meadows Center on Any Federal Watch List?
THE MEADOWS HEALTH AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.