Inspection Reports for Brownsville Nursing and Rehabilitation Center
320 Lorenaly Dr, Brownsville, TX 78526, United States, TX, 78526
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
15.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
337% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 3
Date: Dec 8, 2025
Visit Reason
The inspection was conducted to evaluate compliance with resident rights, care planning, and quality of care standards at Brownsville Nursing and Rehabilitation Center.
Findings
The facility failed to honor a resident's right to refuse or discontinue treatment when the responsible party requested stopping Depakote medication. Additionally, the facility did not review and revise the resident's comprehensive care plan to reflect medication changes and failed to consult the physician regarding medication discontinuation requests, placing residents at risk of not receiving appropriate care.
Deficiencies (3)
Failed to honor the resident's right to refuse or discontinue treatment when requested by the responsible party.
Failed to develop and revise the comprehensive care plan within 7 days of status change related to medication initiation.
Failed to ensure services met professional standards by not consulting the physician concerning discontinuation of medication at responsible party's request.
Report Facts
Residents reviewed: 5
Residents affected: 1
Medication dosage: 250
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON A | Director of Nursing | Named in medication error finding and communication with responsible party |
| DON B | Director of Nursing | Interviewed regarding medication hold procedures and care planning |
| ADON E | Assistant Director of Nursing | Interviewed about medication discontinuation policies and care planning |
| Administrator D | Administrator | Interviewed about facility policies on medication discontinuation |
| APNP L | Advanced Practice Nurse Practitioner | Ordered Depakote and involved in psychiatric services for Resident #1 |
| OM I | Office Manager | Communicated with responsible party and facility regarding medication orders |
| RN F | Registered Nurse | Described procedures for medication hold and discontinuation |
| LVN G | Licensed Vocational Nurse | Documented medication order for Depakote |
| MDS H | MDS Coordinator | Documented care plan meeting notes |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 31, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, specifically focusing on treatment and care according to orders, resident preferences, and goals.
Findings
The facility failed to ensure that Resident #1 had appropriate wound care orders in place upon readmission, resulting in a delay of wound care treatment for two days. This deficient practice posed a risk of inadequate treatment and potential worsening of wounds, although no negative outcomes were reported.
Deficiencies (1)
Failure to provide appropriate wound care orders and treatment for Resident #1's arterial and surgical wounds upon readmission, resulting in a delay of wound care for two days.
Report Facts
Number of residents reviewed for quality of care: 3
Number of arterial and venous ulcers present: 6
BIMS score: 11
Number of sutures: 12
Number of days wound care was delayed: 2
Date of wound care orders start: Aug 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Admitting nurse responsible for verifying and inputting wound care orders for Resident #1 |
| RN B | Registered Nurse, Weekend Supervisor | Responsible for reviewing new admission charts and ensuring appropriate orders were in place |
| LVN C | Licensed Vocational Nurse, Wound Care Nurse | Wound care nurse on the weekend when Resident #1 did not receive wound care |
| DON | Director of Nursing | Oversaw nursing staff and confirmed failure to follow policy regarding wound care orders |
| Wound Care Physician | Physician | Provided treatment orders and follow-up care for Resident #1 |
| ADON D | Assistant Director of Nursing | Interviewed regarding facility policies and training |
Inspection Report
Routine
Deficiencies: 8
Date: Aug 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, nutrition, medication administration, infection control, and food service standards at Brownsville Nursing and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe environment free from hazards, failure to follow physician orders for resident care such as weight monitoring and oxygen administration, improper medication cart security, incorrect diet provision, unsanitary kitchen conditions, and inadequate infection prevention and control practices including improper use of personal protective equipment and failure to follow isolation precautions.
Deficiencies (8)
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Failure to maintain and ensure all chemicals were labeled appropriately and stored properly in residents' bathroom.
Failure to provide enough food/fluids to maintain a resident's health; failure to follow physician orders for weekly weights.
Failure to provide safe and appropriate respiratory care; oxygen administered at incorrect setting.
Failure to ensure medication cart was locked and secured when unattended.
Failure to ensure resident received food prepared in the prescribed pureed diet texture.
Failure to store, prepare, distribute, and serve food in accordance with professional standards; unsanitary kitchen conditions including dirty utensils, unclean surfaces, unlabeled leftovers, and open spices.
Failure to establish and maintain an infection prevention and control program; improper contact isolation and enhanced barrier precautions, failure to wear proper PPE, and allowing residents on contact isolation to freely move increasing risk of cross-contamination.
Report Facts
Residents reviewed for deficiencies: 5
Weight measurements missed: 2
Oxygen setting deviation: 1
Medication carts reviewed: 4
Drinking glasses observed: 120
Spices open to air: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN K | Licensed Vocational Nurse | Nurse for Resident #2 who confirmed oxygen setting error |
| Med-Aide-C | Medication Aide | Acknowledged medication cart was left unlocked |
| RN D | Registered Nurse | Provided information on Resident #35 weight monitoring |
| ADON A | Assistant Director of Nursing | Responsible for weight monitoring oversight and infection control education |
| CNA E | Certified Nursing Assistant | Responsible for weighing residents |
| RN F | Registered Nurse | Identified incorrect diet served to Resident #100 |
| CNA G | Certified Nursing Assistant | Observed not wearing PPE while caring for Resident #9 on contact isolation |
| LVN L | Licensed Vocational Nurse | Failed to wear gown during Enhanced Barrier Precautions for Resident #111 |
| DON | Director of Nursing | Provided information on infection control policies and deficiencies |
| ADON B | Assistant Director of Nursing / Infection Control Practitioner | Provided infection control education and described isolation practices |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Jul 15, 2025
Visit Reason
The inspection was conducted due to complaints and allegations related to medication consent, resident abuse, neglect, and care plan deficiencies at Brownsville Nursing and Rehabilitation Center.
Complaint Details
The complaint investigation included allegations of failure to obtain consent for antipsychotic medications, resident-to-resident abuse incidents, failure to timely report abuse and neglect, inaccurate assessments, incomplete care plans, inadequate supervision leading to resident injury, failure to provide prescribed therapeutic diets, medication errors including lack of physician orders and indications, and incomplete clinical documentation.
Findings
The facility failed to ensure residents were fully informed and consented to antipsychotic medications, failed to prevent and report resident-to-resident abuse, failed to timely report suspected abuse and neglect, failed to provide accurate assessments and comprehensive care plans, failed to provide adequate supervision to prevent accidents, failed to provide therapeutic diets as ordered, failed to ensure proper pharmaceutical services including medication orders and drug regimen reviews, and failed to maintain complete and accurate clinical records.
Deficiencies (11)
Failure to ensure residents were fully informed and consented to antipsychotic medications.
Failure to protect residents from all types of abuse including resident-to-resident altercations causing injuries.
Failure to timely report suspected abuse, neglect, or theft to the State Survey Agency within required timeframes.
Failure to ensure accurate assessments reflecting resident status, including lack of evaluation prior to antipsychotic administration.
Failure to develop and implement comprehensive person-centered care plans with measurable objectives and interventions for resident behaviors.
Failure to review and revise comprehensive care plans after significant changes such as code status changes and resident-to-resident altercations.
Failure to ensure adequate supervision to prevent accidents, resulting in resident elopement and injury.
Failure to provide residents with therapeutic diets as prescribed by the attending physician.
Failure to ensure accurate acquiring, receiving, dispensing, and administering of drugs, including lack of physician order and indication for antipsychotic medication.
Failure to act on pharmacy consultant recommendations regarding psychotropic medication documentation and consent.
Failure to maintain complete and accurate clinical records, including neuro checks, documentation of injuries, and resident-to-resident altercations.
Report Facts
Residents affected: 5
Residents affected: 6
Residents affected: 3
Residents affected: 5
Residents affected: 5
Residents affected: 10
Residents affected: 5
Residents affected: 5
Distance: 150
Weight: 146.6
Weight: 136
Weight: 144.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN J | Licensed Vocational Nurse | Wrote progress notes and administered Haldol to Resident #3 without proper order |
| LVN K | Licensed Vocational Nurse | Administered Haldol to Resident #3 and provided progress notes |
| LVN P | Licensed Vocational Nurse | Called to discontinue Haldol order for Resident #3 and described medication administration requirements |
| PA N | Physician Assistant | Discontinued Haldol order for Resident #3 and discussed need for psychiatric evaluation |
| DON | Director of Nursing | Provided statements on medication administration, consent requirements, and care plan responsibilities |
| MD O | Physician | Denied ordering Haldol for Resident #3 and expressed concerns about the order |
| CNA KK | Certified Nursing Assistant | Reported Resident #8 refused breakfast and described behavior of Resident #2 |
| DM | Dietary Manager | Responsible for ensuring residents received meals according to physician orders |
| LVN A | Licensed Vocational Nurse | Assessed Resident #4 after fall and documented neuro checks |
| LVN F | Licensed Vocational Nurse | Assessed Resident #4 and reported x-ray results to doctor |
| CNA R | Certified Nursing Assistant | Reported observations of Resident #3's behavior |
| LVN C | Licensed Vocational Nurse | Reported Resident #5's injury and assisted with assessments |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to have physician orders for immediate care at admission and failure to provide appropriate wound care and blood sugar checks for Resident #2.
Complaint Details
The complaint investigation focused on Resident #2's care related to lack of physician orders for blood sugar checks and wound care at admission, resulting in an episode of hypoglycemia and delayed wound care treatment. The investigation also included review of clinical documentation for Residents #1, #2, and #7.
Findings
The facility failed to have physician orders for Resident #2's immediate care at admission, including blood sugar checks and wound care orders, resulting in an episode of hypoglycemia requiring hospital transfer. The facility also failed to maintain complete and accurate clinical documentation for multiple residents, including incomplete treatment administration records and medication administration records.
Deficiencies (3)
Failure to provide physician orders for Resident #2's immediate care at admission, including blood sugar checks and wound care orders.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals for Resident #2, including delayed wound care orders and lack of blood sugar checks.
Failure to maintain clinical records that are complete and accurately documented for Residents #1, #2, and #7, including unsigned treatment administration records and medication administration records.
Report Facts
Days without blood sugar checks: 5
Days without wound care orders: 5
Unsigned TAR sections: 13
Unsigned TAR sections: 3
Unsigned TAR sections: 3
Unsigned TAR sections: 2
Unsigned TAR sections: 1
Unsigned MAR sections: 1
Unsigned MAR sections: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Admitting nurse for Resident #2 who failed to obtain blood sugar check orders and delayed wound care orders; verified medication list with NP but did not communicate skin impairments or request blood sugar checks. |
| ADON E | Assistant Director of Nursing | Interviewed regarding facility policies and staff training; confirmed lack of facility policy for diabetic procedures and blood sugar checks; stated LVN A did not follow procedure. |
| DON | Director of Nursing | Interviewed regarding Resident #2's care and documentation; confirmed lack of blood sugar check orders and wound care orders; reviewed unsigned MAR and TAR documentation. |
| LVN M | Licensed Vocational Nurse | Worked with Resident #2 on 04/25/25; did not sign off on MAR for blood sugar checks and insulin orders; stated she forgot to document refusal. |
| LVN D | Licensed Vocational Nurse | Worked with Resident #7 on 05/05/25; did not sign off on MAR for sliding scale insulin; confirmed refusal of blood sugar check. |
| LVN C | Licensed Vocational Nurse | Worked with Resident #2 on 03/13/25; did not sign off on TAR for pressure reduction mattress and treatments. |
| RN B | Registered Nurse | Worked with Resident #1; responsible for signing off TAR; confirmed multiple unsigned TAR sections. |
| LVN I | Licensed Vocational Nurse | Worked with Resident #7 on 04/21/25; did not sign off on MAR for sliding scale insulin; confirmed documentation of blood sugar reading. |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 12, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to comprehensive care plans and pharmaceutical services, specifically focusing on the development and implementation of person-centered care plans and the provision of pharmaceutical services including medication orders for crushed medications.
Findings
The facility failed to develop and implement complete care plans that included measurable objectives and timeframes for residents' wounds, diets, and need for crushed medications for 4 residents. Additionally, the facility failed to obtain and input physician orders for crushed medications for 2 residents, potentially placing residents at risk for inappropriate treatment and medication administration.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including wound care, diet, and need for crushed medications for 4 residents.
Failed to provide pharmaceutical services including obtaining and inputting orders for crushed medications for 2 residents.
Report Facts
Residents reviewed for care plans: 4
Residents affected by care plan deficiency: 4
Residents affected by pharmaceutical services deficiency: 2
BIMS scores: 15
BIMS scores: 3
BIMS scores: 10
BIMS scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS C | MDS Nurse | Responsible for development of resident care plans on long-term side; confirmed deficiencies in care plans |
| MDS D | MDS Nurse | Responsible for development of resident care plans on skilled side; was on leave during inspection |
| DON | Director of Nursing | Reviewed care plans and confirmed deficiencies; provided statements on care plan policies and training |
| MA E | Medication Aide | Provided medications to residents; stated lack of orders for crushed medications; described training and practices |
| ADON B | Assistant Director of Nursing | Responsible for inputting orders; discussed batch orders and discontinuation of crushed medication orders |
| MA F | Medication Aide | Administered medications; aware of need for orders for crushed medications; described training and practices |
| MA G | Medication Aide | Administered medications; aware of need for orders for crushed medications; described training and practices |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 27, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to develop a baseline care plan within 48 hours of a resident's admission, specifically the failure to complete the advance directive section for Resident #356.
Complaint Details
The complaint investigation found that the facility did not complete the advance directive section in the baseline care plan for Resident #356 within 48 hours, and the resident's code status was not documented, potentially leading to unwanted resuscitative measures.
Findings
The facility failed to complete the advance directive section in the baseline care plan for Resident #356 within the required 48-hour timeframe, risking that residents' end-of-life wishes may not be honored. Interviews and record reviews confirmed the absence of code status documentation and incomplete baseline care planning.
Deficiencies (1)
Failure to develop a baseline care plan within 48 hours of admission including the advance directive section for Resident #356.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Interviewed regarding inability to find code status on resident's electronic chart and admission nurse responsibilities. |
| MDS | Interviewed about baseline care plan process and timeline. | |
| Social Services | Interviewed about advance directives discussion during admission and documentation process. |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, medication administration, respiratory care, catheter care, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents, failure to document advance directives and complete baseline care plans timely, incomplete comprehensive care plans, improper catheter care, incorrect oxygen administration, and medication administration errors including failure to ensure medications were taken and properly documented.
Deficiencies (7)
Failure to ensure residents' call lights were within reach, placing residents at risk of not obtaining assistance.
Failure to ensure resident's right to formulate advance directives and document code status.
Failure to develop a baseline care plan within 48 hours of admission including advance directive information.
Failure to develop and implement a comprehensive person-centered care plan reflecting resident's needs, including secured unit placement.
Failure to prevent urinary catheter tubing from touching the floor, risking urinary tract infections.
Failure to provide respiratory care according to physician orders, including incorrect oxygen flow rates for two residents.
Failure to provide pharmaceutical services ensuring accurate medication administration and documentation for multiple residents, including leaving medications unattended and failure to sign off medication administration.
Report Facts
Residents reviewed for call light: 4
Residents reviewed for advance directives: 20
Residents reviewed for baseline care plan completion: 4
Residents reviewed for care plans: 4
Residents reviewed for indwelling catheters: 2
Residents reviewed for oxygen therapy: 4
Residents reviewed for medication administration: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding code status entry, catheter care, and oxygen machine settings. | |
| ADON P | Assistant Director of Nursing | Interviewed about call light accessibility and staff training. |
| DON | Director of Nursing | Interviewed about call light policy, catheter care, oxygen machine settings, medication administration oversight. |
| NA G | Nursing Assistant | Interviewed about call light placement. |
| Med Aide D | Medication Aide | Interviewed about medication administration procedures and errors. |
| RN J | Registered Nurse | Interviewed about medication administration and failure to sign MAR. |
| Med-Aide K | Medication Aide | Interviewed about medication administration and failure to sign MAR. |
| NP F | Nurse Practitioner | Interviewed about medication administration standards. |
| NP G | Nurse Practitioner | Interviewed about medication administration impact on resident outcomes. |
| MDS-LVN | Licensed Vocational Nurse | Interviewed about care plan documentation for secured unit resident. |
| Social Services | Interviewed about advance directives process. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 31, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements, focusing on the accuracy of resident assessments and policies related to food storage brought in by family or visitors.
Findings
The facility failed to ensure accurate coding of resident falls in the Minimum Data Set (MDS) assessments for two residents, which could risk improper care. Additionally, the facility lacked a policy enforcement regarding safe storage and labeling of foods brought in by family, as evidenced by unlabeled, undated, and unrefrigerated food found in a resident's room.
Deficiencies (3)
Failure to ensure Resident #1 was coded in the MDS for a fall.
Failure to ensure Resident #2 was coded in the MDS for a fall.
Failure to enact a policy regarding use and storage of foods brought to residents by family and other visitors, resulting in unlabeled, undated, and unrefrigerated food found in Resident #1's nightstand.
Report Facts
Residents reviewed for accuracy of assessments: 7
Residents affected by inaccurate assessments: 2
Residents reviewed for food storage policy: 3
Residents affected by food storage deficiency: 1
Fall risk assessment score: 7
Fall risk assessment score: 16
Brief Interview of Mental status score: 8
Brief Interview of Mental status score: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse A | MDS Nurse | Interviewed regarding coding of falls and MDS assessments |
| DON | Director of Nursing | Interviewed regarding fall coding and staff training |
| LVN A | Licensed Vocational Nurse | Conducting audits as part of plan of correction |
| Administrator | Facility Administrator | Interviewed regarding MDS assessment oversight and policy enforcement |
| CNA B | Certified Nursing Assistant | Reported on food found in Resident #1's room |
| CNA C | Certified Nursing Assistant | Reported on food storage and labeling issues |
| LVN D | Licensed Vocational Nurse | Reported on food storage and rounds |
| CNA E | Certified Nursing Assistant | Reported on family bringing tamales and food storage |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety and storage |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2024
Visit Reason
The inspection was conducted due to concerns about the facility's failure to maintain accurate and complete medical records for resident #1, specifically regarding documentation of urostomy bag changes and left ankle pain.
Complaint Details
The complaint investigation found that documentation was missing for urostomy bag changes on 01/24/24, 01/31/24, and 02/14/24, and no documentation was present for left ankle pain reported on 02/10/24. Staff interviews indicated care was provided but not documented. The complaint was substantiated as a documentation deficiency with no negative outcomes for the resident.
Findings
The facility failed to document the changing of resident #1's urostomy bag on several dates and did not document the resident's complaint of left ankle pain or related progress notes and change of condition forms. Interviews with staff confirmed care was provided but not documented. The lack of documentation was identified as a deficiency with minimal harm and potential for actual harm.
Deficiencies (1)
Failure to maintain medical records in accordance with accepted professional standards, including incomplete documentation of urostomy bag changes and left ankle pain for resident #1.
Report Facts
Residents reviewed for accuracy of records: 5
Residents affected: 1
Dates missing documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Provided care for resident #1 including urostomy bag changes and left ankle pain assessment; admitted to not documenting care fully. |
| RN B | Registered Nurse | Provided care for resident #1 including urostomy bag changes and relayed x-ray results to MD; admitted to incomplete documentation. |
| DON | Director of Nursing | Acknowledged documentation deficiencies and planned additional training. |
| NP | Nurse Practitioner | Stated no indications that resident #1's orders for urostomy bag changes were not followed. |
| ADM | Administrator | Acknowledged documentation concerns and planned in-service training. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to a complaint or allegation regarding the facility's failure to develop and implement a comprehensive person-centered care plan for Resident #91, specifically related to addressing the resident's severe weight loss.
Complaint Details
The complaint investigation found that Resident #91's severe weight loss was not reflected in the care plan, and the physician was not notified in a timely manner. Interviews with staff including ADON, MDS LVN, DON, and ADM confirmed the failure to update the care plan and notify the physician despite facility policy requiring immediate action upon significant weight loss. The resident's family also reported the resident was weaker since admission.
Findings
The facility failed to update Resident #91's care plan to reflect severe weight loss and did not notify the physician or revise interventions timely. The resident experienced a 7.82% weight loss over one month, and staff interviews confirmed the failure to act promptly on this significant change, potentially risking further deterioration of the resident's health.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, including addressing severe weight loss for Resident #91.
Report Facts
Weight loss: 9.2
Residents reviewed for care plan: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON B | Assistant Director of Nursing | Responsible for monitoring resident weights; verified severe weight loss but did not notify MDS LVN as required. |
| MDS LVN | MDS Licensed Vocational Nurse | Unable to locate interventions for weight loss in care plan or notification to physician; sent revised care plan and documentation after surveyor inquiry. |
| DON | Director of Nursing | Stated facility policy to notify dietician, MD, and revise care plan immediately upon significant weight loss; contacted dietician and MD after surveyor inquiry; revised care plan after questioning. |
| ADM | Administrator | Acknowledged facility policy to notify MD, family, and revise care plan for weight loss; unsure why this was not done for Resident #91. |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pharmaceutical services, medication storage, and infection control at Brownsville Nursing and Rehabilitation Center.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan reflecting severe weight loss for one resident, failed to remove expired medication from a medication cart, failed to secure narcotic medications properly, and failed to ensure proper infection control practices by not disinfecting blood pressure cuffs between resident use.
Deficiencies (4)
Failed to develop and implement a comprehensive person-centered care plan reflecting severe weight loss for Resident #91.
One medication (Morphine 100mg/5ml) was found expired in the 200 Hall medication cart.
Narcotic lock box in medication room refrigerator was not affixed to the refrigerator.
Failed to disinfect blood pressure cuff between use on different residents (Resident #249 and Resident #252).
Report Facts
Weight loss: 9.2
Weight loss percentage: 7.82
Medication expiration date: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON B | Assistant Director of Nursing | Responsible for monitoring resident weights and notifying MDS LVN; interviewed regarding weight loss care plan failure |
| MDS LVN | Licensed Vocational Nurse | Unable to locate interventions for weight loss in care plan; sent revised care plan and diet order via email |
| DON | Director of Nursing | Acknowledged failure to update care plan and notify physician; responsible for medication policies and infection control |
| ADM | Administrator | Interviewed regarding policies and consequences related to weight loss care plan and expired medication |
| ADON A | Assistant Director of Nursing | Acknowledged expired Morphine medication found in medication cart |
| MA A | Medication Aide | Observed failing to disinfect blood pressure cuff between residents |
| LVN A | Licensed Vocational Nurse | Described proper blood pressure cuff cleaning procedure and consequences of non-compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to develop and implement comprehensive, person-centered care plans for residents after fall incidents.
Complaint Details
The complaint investigation found that the facility did not care plan falls sustained by Resident #2 on 12/17/2022 and Resident #3 on 01/27/2023. The falls were not included in incident reports or care plans, increasing risk of injury. The MDS nurse and DON acknowledged these omissions during interviews.
Findings
The facility failed to develop care plans addressing fall incidents for two residents (Residents #2 and #3), placing them at risk of not receiving appropriate care to meet their physical, mental, and psychosocial needs. Multiple falls were documented without corresponding care plan updates or incident reports.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, with measurable objectives and timeframes, for Residents #2 and #3 after fall incidents.
Report Facts
Fall incidents for Resident #2: 4
Fall incidents for Resident #3: 7
BIMS score Resident #2: 5
BIMS score Resident #3: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN F | Licensed Vocational Nurse | Author of progress notes documenting fall incidents for Residents #2 and #3 |
| MDS Nurse | Responsible for completing comprehensive care plans; acknowledged failure to care plan falls | |
| DON | Director of Nursing | Acknowledged failure to care plan falls and discussed risks during interviews |
| ADON | Assistant Director of Nursing | Participated in interview confirming failure to care plan Resident #3's fall |
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