Inspection Report Summary
The most recent inspection on August 21, 2025, identified a deficiency related to incomplete care planning, specifically the omission of a mechanically altered diet for a resident. Earlier inspections showed a pattern of deficiencies involving care planning, medication management, infection control, and food safety, with several complaint investigations substantiating issues such as improper medication counts, failure to follow care plans, and inadequate supervision leading to resident injuries. Enforcement actions included staff suspensions and policy revisions related to medication handling, but fines or license suspensions were not listed in the available reports. Most complaints were substantiated, including notable cases involving medication errors and resident fractures due to improper transfers. The facility’s recent inspection results suggest ongoing challenges with care planning and medication management, with no clear trend of overall improvement or worsening.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
214% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically to assess whether the facility developed and implemented complete, person-centered care plans that included measurable objectives and timeframes to meet residents' medical, nursing, and psychosocial needs.
Findings
The facility failed to include Resident #1's mechanically altered diet on her comprehensive care plan, which could place residents at risk for not receiving safe and appropriate care. Interviews with staff confirmed the omission, and training documentation was lacking. The Director of Nursing acknowledged the deficiency and emphasized the importance of including diet information in care plans.
Deficiencies (1)
Failed to develop and implement a complete care plan that meets all the resident's needs, including the mechanically altered diet for Resident #1.
Report Facts
Residents reviewed for comprehensive care plans: 5
Residents affected: Few
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse B | MDS Nurse | Responsible for completing Resident #1's comprehensive care plan; acknowledged omission of diet in care plan |
| Regional MDS Nurse | Regional MDS Nurse | Provided training on care planning including nutrition and diet care planning |
| DON | Director of Nursing | Reviewed and monitored care plans; acknowledged deficiency and importance of including diet in care plans |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 8, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure that narcotic medication for Resident #1 was received and counted appropriately upon admission.
Complaint Details
The complaint investigation found that the narcotic medication count for Resident #1 was short by 15 pills. The facility staff did not follow proper policy and protocol for receiving and counting controlled substances. The investigation included interviews, staff suspension, and policy revisions. The resident was never without medication and was not believed to have been abused or neglected.
Findings
The facility failed to properly count and document narcotic medication Oxycodone-Acetaminophen Oral Tablet 10-325 MG for Resident #1, resulting in a shortage of 15 pills. Staff interviews revealed lapses in following medication receipt policies, and an investigation was initiated including staff suspension and policy updates.
Deficiencies (1)
Failure to ensure that drugs and biologicals for Resident #1 were received and counted appropriately, resulting in a narcotic medication shortage of 15 pills.
Report Facts
Medication shortage: 15
Medication count on bottle: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Staff Nurse | Received narcotic medication from hospice nurse but did not count the pills as required |
| LVN A | Licensed Vocational Nurse | Gave report to RN A and signed in other medications but did not see narcotics counted |
| LVN B | Licensed Vocational Nurse | Counted narcotic medication on July 11, 2025, and found the count was off by 15 pills; notified ADON and DON |
| Director of Nursing | DON | Notified of medication discrepancy, initiated investigation, interviewed staff, and reviewed records |
| Administrator | Facility Administrator | Informed of medication discrepancy, coordinated investigation, updated policies, and placed staff on suspension |
Inspection Report
Routine
Deficiencies: 5
Date: May 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASRR screening, nutritional status, medication storage and labeling, food safety and sanitation, and infection prevention and control in the nursing facility.
Findings
The facility failed to complete accurate PASRR evaluations for a resident with mental illness diagnoses, failed to maintain adequate nutritional monitoring for a resident with significant weight loss, failed to properly label and dispose of expired medications and supplies, failed to maintain food safety standards in the kitchen including labeling, sanitation, and storage, and failed to properly handle and dry linens to prevent infection risks.
Deficiencies (5)
Failed to complete accurate PASRR evaluation and referral for Resident #83 with mental illness diagnoses.
Failed to maintain acceptable nutritional status and timely weight monitoring for Resident #50 with significant weight loss of 21%.
Failed to properly label and dispose of expired medications and supplies on medication carts and medication room.
Failed to ensure food safety and sanitation in the kitchen including unlabeled and undated food items, lack of internal thermometers, dirty equipment, and open dumpster doors.
Failed to properly handle, wash, and dry linens and resident clothing, leaving wet items overnight increasing risk of cross contamination and infection.
Report Facts
Weight loss: 47
Expired medication count: 3
Expired syringes count: 50
Containers of unlabeled/undated food: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LA H | Laundry Aide | Left wet linen and resident clothing overnight without drying, admitted to doing this 3-4 times. |
| LA I | Laundry Aide | Observed wet linen and resident clothing left overnight, rewashed after in-service. |
| FSS | Food Service Supervisor | Responsible for labeling and cleanliness in kitchen, acknowledged multiple sanitation and labeling failures. |
| ADON-B | Assistant Director of Nursing | Discussed weight monitoring failures and lack of physician notification for Resident #50. |
| DON | Director of Nursing | Discussed weight monitoring procedures and acknowledged missed alerts and weight loss concerns. |
| RD | Registered Dietitian | Flagged weight loss concerns for Resident #50, clarified job duties regarding order review. |
| MDS Nurse | Nurse | Signed PASRR Form 1012 for Resident #83, admitted to misreading instructions delaying referral. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to comprehensive care planning and infection prevention and control practices at the nursing home facility.
Findings
The facility failed to develop and implement a person-centered comprehensive care plan for Resident #8 addressing habitual misplacing of items and accusations of theft, and failed to ensure proper hand hygiene by CNA C during incontinent care for Resident #1, potentially placing residents at risk of harm and infection.
Deficiencies (2)
Failure to develop and implement a complete care plan that meets all the resident's needs, including measurable objectives and timeframes, specifically for Resident #8's habitual losing or misplacing of items and accusing others of theft.
Failure to ensure CNA C performed hand hygiene after removing gloves during incontinent care for Resident #1.
Report Facts
Residents reviewed for comprehensive care plans: 5
Residents reviewed for infection control practices: 5
BIMS score: 10
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA C | Certified Nursing Assistant | Named in infection control deficiency for failing to perform hand hygiene after glove removal. |
| ADON A | Assistant Director of Nursing | Interviewed regarding hand hygiene and care plan deficiencies. |
| ADON B | Assistant Director of Nursing | Interviewed regarding care plan deficiencies for Resident #8. |
| MDS nurse | Interviewed regarding care plan updates for Resident #8. | |
| SW | Social Worker | Interviewed regarding care plan updates and Resident #8's behavior. |
| DON | Director of Nursing | Interviewed regarding hand hygiene practices and infection risk. |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 4, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment, specifically regarding room temperature control for residents.
Findings
The facility failed to maintain Resident #1's room temperature at or below 81 degrees, with the temperature recorded at 81.6 degrees. Despite multiple reports from staff and the resident about the room being too hot, no corrective action was taken until the inspection, posing a risk of an uncomfortable and unsafe environment.
Deficiencies (1)
Failed to ensure Resident #1's room temperature was maintained at or below 81 degrees.
Report Facts
Room temperature: 81.6
Temperature range: 71
Temperature range: 81
Temperature range: 72
Temperature range: 73
Time since air conditioner service: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Charge Nurse | Mentioned by CNAs regarding reports of room temperature concerns |
| Maintenance Director | Checked room temperature and responsible for maintenance; had not serviced air conditioner in 12 months | |
| Administrator | Verified room temperature and instructed installation of window unit |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement baseline care plans and to provide appropriate treatment and care according to physician orders and resident preferences.
Complaint Details
The complaint investigation found substantiated deficiencies related to care planning and wound care practices that did not meet professional standards, potentially placing residents at risk.
Findings
The facility failed to develop and implement a baseline care plan for Resident #2 during the 20 days of stay, which could risk residents not receiving effective person-centered care. Additionally, the facility failed to ensure the wound care nurse followed physician orders for Resident #1 by not pat drying the wound before applying dressing, risking infection.
Deficiencies (2)
Failure to develop and implement a baseline care plan for Resident #2 during the 20 days at the facility.
Failure to ensure wound care nurse followed doctor's orders to pat dry wound before applying dressing for Resident #1.
Report Facts
Residents reviewed for care plans: 5
Residents reviewed for quality of care: 2
Days Resident #2 was at facility: 20
BIMS score Resident #2: 13
BIMS score Resident #1: 9
Wound care observation date: Feb 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMN C | Care Manager Nurse | Oversaw long-term resident care plans and provided interview details about care plan processes |
| CMN D | Care Manager Nurse | Oversaw short-term resident care plans and provided interview details about care plan processes |
| LVN E | Licensed Vocational Nurse | Provided interview details about care plan form completion on admission |
| ADON A | Assistant Director of Nursing | Provided interview details about baseline care plan development and sign-off |
| ADON B | Assistant Director of Nursing | Provided interview details about care plan development and responsibility |
| Wound Care nurse | Observed performing wound care and admitted to not pat drying wound as ordered | |
| DON | Director of Nursing | Provided interview confirming wound care nurse should have followed orders and discussed infection control in-service |
Inspection Report
Deficiencies: 1
Date: Jul 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with medication storage regulations, specifically ensuring that drugs and biologicals are stored in locked compartments according to professional standards.
Findings
The facility failed to ensure that one of nine medication carts was stored in a locked compartment. The medication cart on the 600 hall was left unlocked and unattended by LVN C, potentially placing residents at risk of accessing non-narcotic medications.
Deficiencies (1)
Medication cart left unlocked and unattended, allowing potential resident access to non-narcotic medications.
Report Facts
Medication carts observed: 9
Duration cart unlocked: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN C | Named in medication cart left unlocked finding | |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interview regarding medication cart policy and expectations |
| Administrator | Administrator | Provided interview regarding counseling and staff in-service on medication cart policy |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 6, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to develop and implement policies to prevent abuse, neglect, and theft, and failure to properly investigate a resident's injury of unknown origin.
Complaint Details
The complaint investigation focused on abuse, neglect, and exploitation allegations related to Resident #70's skin tear injury. Interviews with staff and resident indicated no witnessed abuse, but the facility failed to complete an incident report or investigation. The investigation also included a narcotic count discrepancy involving Resident #81's medication, with missing Lorazepam tablets and improper documentation. The police were notified regarding the suspected drug diversion.
Findings
The facility failed to develop and implement written policies and procedures to prevent abuse, neglect, and exploitation, and failed to conduct an investigation of a resident's skin tear injury. Additionally, the facility failed to provide pharmaceutical services ensuring accurate medication counts, resulting in missing narcotic tablets and improper documentation.
Deficiencies (3)
Failed to develop and implement policies and procedures to prevent abuse, neglect, and theft for one resident.
Failed to conduct an investigation of Resident #70's skin tear injury of unknown origin.
Failed to provide pharmaceutical services ensuring accurate acquiring, receiving, dispensing, and administering of drugs; specifically, failure to account for 2 missing Lorazepam tablets and failure to accurately document drug counts.
Report Facts
Deficiencies cited: 3
Missing medication tablets: 2
BIMS score: 8
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Involved in narcotic count and medication documentation related to missing Lorazepam tablets |
| RN B | Registered Nurse | Involved in narcotic count and medication documentation related to missing Lorazepam tablets |
| LVN D | Licensed Vocational Nurse | Created nursing note documenting Resident #70's skin tear; failed to complete incident report |
| CNA G | Certified Nursing Assistant | Worked with Resident #70 on the night of injury; provided information on resident care and incident reporting |
| RN E | Registered Nurse | Described process for skin tear assessment and incident reporting |
| LVN F | Licensed Vocational Nurse | Described process for skin tear assessment and documentation |
| ADON A | Assistant Director of Nursing | Described skin tear procedures and incident reporting |
| DON | Director of Nursing | Discussed skin tear procedures, incident reporting failures, and narcotic count procedures |
| Administrator | Facility Administrator | Provided information on skin tear process and incident review; confirmed police notification for drug diversion |
| ADMIN | Administrator | Confirmed police notification and event number for narcotic discrepancy incident |
Inspection Report
Routine
Deficiencies: 10
Date: Mar 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident privacy, safety, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy and confidentiality, unsafe water temperatures, inadequate investigation of resident injury, failure to implement physician orders for pressure ulcer prevention, medication management discrepancies including drug diversion risk, failure to perform monthly pharmacist drug regimen reviews, improper storage and sanitation of medications and food, and deficiencies in infection prevention and control practices.
Deficiencies (10)
Failure to ensure residents' personal and medical records privacy and confidentiality; nurse's station computer left unlocked exposing sensitive resident information.
Failure to maintain bathroom sink hot water temperatures below 110 degrees Fahrenheit, risking burn injuries to residents.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and exploitation; failure to investigate resident injury of unknown origin.
Failure to provide treatment and care according to physician orders; Resident #18 was not wearing ordered Prevalon Boots to prevent pressure ulcers.
Failure to provide pharmaceutical services ensuring accurate medication counts; missing tablets of Lorazepam and inaccurate documentation by nursing staff.
Failure to ensure monthly drug regimen review by licensed pharmacist for Resident #4; missing reviews for January and February 2024.
Failure to implement gradual dose reductions for psychotropic medications for Resident #4 since 09/2023.
Failure to store all drugs and biologicals in locked compartments; medication cart on Hall 300 was found unlocked and unattended.
Failure to store, prepare, distribute, and serve food in accordance with professional standards; including unsanitary juice dispenser guns, unclean equipment, improper dishwasher temperatures, inaccurate chemical logs, expired and unlabeled dry goods, open spices, expired items in nutrition room refrigerator, and failure to follow cleaning schedules.
Failure to maintain an infection prevention and control program including Legionella monitoring; unbagged ventilator mask and oxygen nasal cannula tubing for Resident #89; improper perineal care for Resident #70 with dirty barrier linen left under resident's buttocks.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 24
Dishwasher temperature: 110
Dishwasher temperature: 123
Sanitizer concentration: 200
Expired dry milk use-by date: Jan 25, 2024
Expired pancake mix use-by date: Jan 17, 2024
Expired bread use-by date: Mar 2, 2024
Expired tube feed expiration date: Mar 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Named in privacy breach finding for leaving nurse's station computer unlocked | |
| LVN D | Licensed Vocational Nurse | Named in failure to investigate resident injury and failure to complete incident report |
| CNA G | Certified Nursing Assistant | Interviewed regarding resident injury and abuse reporting |
| RN E | Registered Nurse | Interviewed regarding resident injury and abuse reporting |
| LVN F | Licensed Vocational Nurse | Interviewed regarding resident injury and abuse reporting |
| ADON A | Assistant Director of Nursing | Interviewed regarding resident injury and abuse reporting and infection control |
| RN A | Registered Nurse | Named in medication count discrepancy and narcotic count |
| RN B | Registered Nurse | Named in medication count discrepancy and narcotic count |
| LVN A | Licensed Vocational Nurse | Named in medication cart left unlocked on Hall 300 |
| DM | Dietary Manager | Interviewed regarding kitchen sanitation and cleaning schedules |
| CS | Central Supply | Interviewed regarding nutrition room stocking and maintenance |
| LVN B | Licensed Vocational Nurse | Guardian Angel Advocate for Resident #89, interviewed about oxygen equipment |
| CNA C | Certified Nursing Assistant | Named in infection control finding for improper perineal care |
| DON | Director of Nursing | Interviewed regarding multiple findings including medication management, infection control, and resident care |
| ADMIN | Administrator | Interviewed regarding Legionella testing and police notification for medication discrepancy |
| MD | Medical Doctor | Interviewed regarding medication cart maintenance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 25, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to notify a resident, the resident's representative, and the ombudsman in writing about the transfer or discharge of Resident #1, including the reasons for the move and appeal rights.
Complaint Details
The complaint involved failure to notify Resident #1, the responsible party, and the ombudsman of the transfer/discharge in writing. The facility was found to have not provided discharge papers or a discharge summary. The Ombudsman became involved after the resident remained at the acute behavioral hospital for an extended period due to lack of placement. The complaint was substantiated based on interviews and record reviews.
Findings
The facility failed to provide timely written notification to Resident #1, the responsible party, and the ombudsman about the transfer/discharge to an acute behavioral hospital. Additionally, the facility did not complete a discharge summary for Resident #1, and no discharge papers were provided to the receiving facility. The resident was transferred multiple times due to behavioral issues, and the facility was unable to meet Resident #1's needs, resulting in extended stay at the behavioral hospital and delayed placement at another facility.
Deficiencies (2)
Failed to notify the resident, resident's representative, and ombudsman in writing of the transfer or discharge and the reasons for the move before transferring or discharging Resident #1.
Failed to complete a discharge summary for Resident #1 on the discharge date.
Report Facts
Residents affected: 1
Days Resident #1 stayed at acute behavioral hospital: 97
Discharge date: Sep 1, 2023
Phone notification date: Sep 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker (SW) | Provided information about Resident #1's behavior, hospital transfers, and notification status | |
| Administrator | Discussed Resident #1's behavior, discharge decisions, and lack of notification to resident and ombudsman | |
| Director of Utilization Review at acute behavioral hospital | Provided information about Resident #1's stay, discharge readiness, and placement difficulties | |
| Director of Nursing (DON) | Confirmed no discharge summary was completed or provided |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 19, 2023
Visit Reason
The inspection was conducted due to a complaint or allegation regarding medication cart security and storage practices at the facility.
Complaint Details
The visit was complaint-related, focusing on medication cart security. The complaint was substantiated as the medication cart was found unlocked and unattended.
Findings
The facility failed to ensure that the 100 hall medication cart was locked and unattended at the nurses station, posing a risk of medication misappropriation or accidental ingestion. Interviews and observations confirmed the medication cart was left unlocked, contrary to facility policy.
Deficiencies (1)
The 100 hall medication cart was left unlocked and unattended at the nurses station, risking misappropriation or accidental ingestion of medications.
Report Facts
Medication carts reviewed: 6
Medication carts with deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMA A | Took ownership of the unlocked medication cart and admitted forgetting to lock it | |
| LVN A | Present near the medication cart during observation | |
| LVN B | Present near the medication cart during observation | |
| ADON | Assistant Director of Nursing | Interviewed regarding medication cart locking policy |
| DON | Director of Nursing | Interviewed regarding medication cart locking policy |
Inspection Report
Routine
Census: 106
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically to assess compliance with transmission-based precautions and infection control signage.
Findings
The facility failed to maintain an infection control program designed to prevent the transmission of communicable diseases, as evidenced by the absence of transmission-based precaution signage on a resident's room door despite the presence of a contagious infection. Interviews with staff confirmed inconsistent posting of required signage, posing a risk of infection spread to residents, staff, and visitors.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program, including lack of transmission-based precaution signage on resident room door.
Report Facts
Residents affected: 106
Date of infection control in-service: May 15, 2023
Date resident placed on isolation precautions: May 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Charge Nurse | Interviewed regarding transmission-based precautions and signage |
| ADON | Assistant Director of Nursing | Interviewed regarding signage posting and infection control rounds |
| DON | Director of Nursing | Interviewed regarding infection control signage and oversight |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop and implement a person-centered care plan for Resident #3, specifically related to proper transfer methods.
Complaint Details
The complaint investigation found that Resident #3 was not transferred according to the care plan requiring 2-person assisted Hoyer lift transfers. Staff performed 1-person transfers without using the Hoyer lift, leading to Resident #3 sustaining fractures to both femurs. Staff were unaware of the care plan requirements until recently. The Director of Nursing confirmed the deficiencies and the risk of injury due to improper transfers.
Findings
The facility failed to follow Resident #3's care plan requiring 2-person assisted Hoyer lift transfers, instead performing 1-person physical assists. This failure led to Resident #3 sustaining fractures to both femurs. Staff interviews confirmed lack of awareness of the care plan requirements and improper transfer techniques. The Director of Nursing confirmed staff were not following the care plan and that this could cause injuries such as fractures.
Deficiencies (2)
Failed to develop and implement a complete care plan with measurable objectives and timeframes for Resident #3.
Failed to ensure adequate supervision and assistance to prevent accidents, resulting in Resident #3 sustaining fractures due to improper transfers.
Report Facts
Residents reviewed for comprehensive care plans: 6
Dates of 1-person transfers documented by CNA A: 8
Dates of 1-person transfers documented by CNA B: 2
Dates of 1-person transfers documented by CNA C: 1
Dates of 1-person transfers documented by CNA D: 1
Dates of 1-person transfers documented by CNA E: 3
Date of fracture diagnosis: 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Documented multiple 1-person transfers of Resident #3 and admitted not following care plan due to unawareness of Hoyer lift requirement. |
| CNA B | Certified Nursing Assistant | Documented 1-person transfers but stated she would transfer Resident #3 as a 2-person transfer; unaware Resident #3 was a Hoyer transfer. |
| CNA C | Certified Nursing Assistant | Documented 1-person transfer but stated she would transfer Resident #3 as a 2-person transfer; unaware Resident #3 was a Hoyer transfer until recently. |
| CNA D | Certified Nursing Assistant | Documented 1-person transfer; did not recall working with Resident #3. |
| CNA E | Certified Nursing Assistant | Documented 1-person transfers; unaware Resident #3 was a Hoyer transfer; stated fracture may have been caused by fall or drop. |
| LVN F | Licensed Vocational Nurse | Assessed Resident #3's left knee pain and notified nurse practitioner; unaware how fracture occurred. |
| DON | Director of Nursing | Confirmed staff were not following Resident #3's care plan; conducted audit and in-serviced staff; stated improper transfers could cause injuries. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding significant medication errors involving the administration of Potassium Chloride ER to Resident #43.
Complaint Details
The complaint investigation found that Resident #43 was administered Potassium Chloride ER tablets crushed and dissolved in water 24 times in January 2023 by Medication Aide (MA) A, which was against physician orders and medication guidelines. The facility substantiated the complaint and took corrective actions including notifying the doctor, monitoring the resident, and providing staff in-services.
Findings
The facility failed to ensure residents were free from significant medication errors when Resident #43 was administered Potassium Chloride ER tablets crushed and dissolved in water 24 times from 01/01/23 through 01/20/23, contrary to physician orders and medication guidelines. The medication error posed risks of serious injury including cardiac arrest. Staff interviews confirmed the medication should not have been crushed, and corrective actions including in-services and order modifications were initiated.
Deficiencies (1)
Failure to ensure residents were free from significant medication errors related to crushing and dissolving Potassium Chloride ER tablets for Resident #43.
Report Facts
Medication administration instances: 37
Medication administration errors: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA A | Medication Aide | Administered Potassium Chloride ER tablets crushed and dissolved in water |
| LVN C | Licensed Vocational Nurse | Interviewed regarding medication administration and confirmed no order to crush Potassium Chloride ER |
| DON | Director of Nursing | Oversaw corrective actions, in-serviced staff, and monitored Resident #43 |
| ADON D | Assistant Director of Nursing | Interviewed about medication administration and order review |
| ADON E | Assistant Director of Nursing | Notified doctor about medication error and added 'DO NOT CRUSH' to order |
| ADON F | Assistant Director of Nursing | Observed medication rounds and explained risks of crushing Potassium Chloride ER |
| Administrator | Facility Administrator | Notified of medication error and confirmed in-services and doctor notification |
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