Katy Manor

Inspectors wroteBased on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to transcribe a wound treatment order for one resident (Resident #2) and failed to obtain an order for Lyrica upon admission for one resident (Resident #156). The facility census was 47. 1. Review of the facility's Wound Treatment Management Policy, undated, showed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment, dated 02/26/25, showed staff assessed the resident as follows: -Substantial/maximal assistance with lower body dress, and put on/off footwear; -Partial/moderate assistance with sit to lying, and sit to stand; -Resident at risk for pressure ulcer; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to remove and destroy expired tube feedings and intravenous (IV) supplies from one of one medication storage room, and failed to discard expired insulin from one of one sampled insulin storage cart. The facility's census was 47. 1. Review of the facility's policy titled, Medication Storage, undated, showed the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. 2. Observation on 03/24/25 at 9:38 A.M., showed the medication storage room contained: [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify one resident's (Resident #1) physician after a significant medication error. The facility census was 56. 1. Review of the facility's Notification of Change policy, undated, showed staff are directed to promptly consult the resident's physician when there is a change requiring notification. This includes adverse drug reaction and potential to require physician intervention. These may include adverse consequences, acute condition and exacerbation of chronic condition. The primary physician will be notified regardless of whether the resident is receiving Hospice Services. 2. Review of Resident #1's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/29/24, showed staff assessed the resident received opioid seven days of the seven day look back period. [...]

Inspectors wroteBased on interview, and record review, facility staff failed to ensure one resident (Resident #1) remained free from significant medication errors, when facility staff administered double the prescribed dosage of Fentanyl to the resident. The census was 56. 1. Review of the facility's Medication Administration policy, undated, showed staff are directed as follows: -Ensure right dosage, right time and right documentation; -Review Medication Administration Record (MAR) to identify medication to be administered; -Administer within 60 minutes prior to or after scheduled time; -Sign MAR after administered; -If medication is a controlled substance, sign narcotic book; -Correct any discrepancies and report to nurse manager. 2. Review of the facility's Controlled Substance policy, undated, showed staff are directed as follows: [...]

Inspectors wroteBased on interview, and record review, facility staff failed to meet professional standards when staff did not obtain orders for catheter care for three residents (Resident #1, #2, and #3) out of three sampled residents, and did not obtain orders for a colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall) and colostomy care for one resident (Resident #3) out of one sampled resident. The facility census was 53. 1. Review of the facility's Medication and Treatment Orders Policy, undated, showed medications, treatments, and care tasks shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Review of the facility's Routine Catheter Care Policy, undated, showed catheter care is to be provided once a shift and as needed. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure one resident (Resident #1) out of three sampled residents code status (the level of medical interventions a resident wishes to have if their heart or breathing stops) was documented correctly throughout the medical record. The facility census was 54. 1. Review of the facilty's resident rights policy, dated 2022, showed staff are directed as follows: -Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -Each resident has the right to choose health care services consistent with his or her interests. Review of the facility's Advanced Directive policy, dated 2020, showed staff are directed as follows: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the residents environment remained free of accident hazards when staff failed to store hazardous chemicals, safely propel one resident (Resident #34) in a wheelchair, lock unattended medication carts, and provide safe mechanical lift transfers for two residents (Resident # 5, and #14). The facility census was 51. 1. Review of the facility's policy titled, Hazardous Chemical Inventory Listing, revised April 2013, showed staff are directed to the following: -A hazardous chemical is any chemical which is classified as a (an): -Physical hazard; -Health hazard; -Simply asphyxiant; -Combustible dust; -Pyrophoric gas; -Hazard not otherwise classified. 2. Observation on 11/30/23 at 8:42 A.M., showed the housekeeping cart unattended and unlocked on the 100 hallway. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain a medication error rate less than five percent (%) out of 37 opportunities observed, 24 errors occurred, which resulted in a 64.8% error rate which effected five resident's (Resident #7, #12, #17, #18, and #42) of the five sampled resident's. The facility census was 51. 1. Review of the facility's Administering Medications policy, undated, showed the Director of Nursing (DON) Services supervises and directs all personnel who administer medications. Review showed: -Medications are administered in accordance with prescribed orders, including any time frame; -Medication administration times are determined by the resident need and benefit, not staff convenience; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store and label medication in a safe and effective manner in one of one medication storage rooms, and one of one medication carts. The facility census was 51. 1. Review of the facility's policy titled, Storage of Medications, undated, showed staff were directed as follows: -Drugs and biological's shall be stored in the packaging, containers or other dispensing systems in which they are received; -The nursing staff shall be responsible for maintain medication storage and preparation areas in a clean, safe, and sanitary manner; -The facility shall not use discontinued, outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to maintain professional standards of documentation when staff failed to complete weekly skin assessment per physican orders for one residents (Resident #3) and failed to ensure safe medication administration for three residents (Resident #18, #31, and #35). The facility census was 51. 1. Review of the facility's Skin Ulcer-Wound policy, undated, showed: -All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations; -Measurements must be completed weekly by the same licensed person when at all possible; -A wound assessment should be documented in the nurse's notes (or other documentation location) with each dressing change. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure the ice machine drained through an air gap. Facility staff also failed to thaw meat in a manner to prevent the growth of food-borne pathogens and food-borne illness. The facility census was 51. 1. Review of the facility's Policy for Care and Maintenance of Ice Machine, undated, showed staff were directed to check the drain line weekly and clean as needed. Observation on 10/4/22 at 11:50 A.M., showed an outside company technician serviced the ice machine. Further observation showed the ice machine drained into the floor drain without an air gap. The ice machine drainpipe contained a black substance on the lower quarter inch of the pipe which hung below floor level. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure residents who were unable to complete their own activities of daily living (ADL), received the necessary care and services to maintain good personal hygiene when staff failed to provide hair care and nail care, change dirty clothing, and provide showers to seven residents (Residents #24, #28, #32, #34, #35, #40, #42, #198). The facility census was 51. 1. Review of the facility's Policy for Activities of Daily Living, dated January 2019, showed: -ADLs refers to the residents' daily self-care activities. The ability or inability of the resident to perform ADLs is a measurement of their functional status; -A resident who cannot perform essential ADLs may have poorer quality of life or be unsafe in their environment; -Residents will be assisted with ADLs as needed based on their functional status; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure razors/sharps and hazardous chemicals were stored in a safe manner, and failed to lock an unattended treatment and medication cart. Additionally, staff failed to properly propel an unidentified resident and one additional resident (Resident #9) in wheelchairs in a manner to prevent accidents, and failed to safely transfer three residents (Resident #1, #26, and #28). The facility census was 51. 1. The facility did not provide a Hazardous Chemicals/Sharps Storage Policy. Observation on 10/6/22 at 7:05 A.M., showed 300 hall Spa unlocked and unattended as residents walked down the hallway and sat in the day room. Further observation showed an unlocked and unattended cabinet that contained: -Two pairs of scissors; -One can of Ultrasure Deodorant spray, labeled Contact Poison Control if ingested; [...]

Inspectors wroteBased on interview, and record review, facility staff failed to follow their Facility-Wide assessment to ensure a sufficient number of qualified staff were available to meet the needs of their residents. Additionally, facility staff failed to review and update the assessment when their resident population increased from 37 to 51. The facility census was 51. 1. Review of the facility's Facility-Wide Assessment, dated 3/1/22, showed staff documented the assessment occurred with a census of 37 residents. Additionally, staff documented the following staff requirements to meet the needs of the residents: -Day Shift: -Three Registered Nurses (RN); -Two Licensed Practical Nurses (LPN); -Six Nurse Aides (NA); -One Restorative Aide (RA); -One Certified Mediation Technician (CMT); -Night Shift: -One LPN; -Three NA's. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Resident #1 and #28). Additionally, facility staff failed to clean a mechanical lift (mechanical device used to lift and transfer a resident) between resident uses. The facility census was 51. 1. Review of the facility's Hand Hygiene Policy and Procedure, dated March 2020 showed the purpose is to reduce the risk of the incidence of Healthcare-associated infections. Further review showed: -Indications for handwashing and hand rubbing include: -When hands are visibly dirty or are visibly soiled with blood or other bodily fluids; -After contact with a resident's intact skin; [...]

Inspectors wroteBased on interview and record review, staff failed to provide necessary behavioral health services and/or contact the physician to support one resident's (Resident #49) psychosocial well-being after the resident had voiced concerns with new hallucinations and depression, and when the resident's family member voiced concerns to staff in regard to the resident's mental status and history of self harm. The facility census was 51. 1. Review of the facility's Notification of Physician policy, dated September 2017, showed: -It is the policy of the facility that they must immediately inform the resident's physician when there is an accident/incident involving the resident which results in injury and has the potential for requiring physician intervention and a significant change in the resident's physical, mental or psychological status (i.e. significant change in mood or behavior); [...]