Cityview Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 5801 Bryant Irvin Rd, Fort Worth, Texas 76132
- CMS Provider Number
- 675622
- Inspections on file
- 45
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Cityview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with metastatic cancer, acute kidney failure, bowel and bladder incontinence, and dependence on staff for toileting hygiene was found late in the morning lying on a draw sheet saturated with dried urine that he reported had not been changed since the previous evening, and he stated no one had checked on him that morning. The assigned CNA reported she had not yet checked on him, was busy with other residents, and was unaware of his incontinence, despite adequate CNA staffing on the hall. The ADON stated there was no reason the resident should have remained on dirty linen and that staff were expected to round on all residents at the start of their shifts to assess needs, noting that urine-soaked linens could cause skin breakdown or irritation. Examination of the resident’s skin showed no breakdown, and other residents on the hall reported no issues with linen changes, while facility policy on ADLs did not specifically address linen changing.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that call light cords were not within reach for several residents who were in bed, with cords stored in dressers, under mattresses, or hanging from lights above the bed. Multiple residents were unable to locate their call lights, and staff interviews confirmed that call lights are required to be accessible according to facility policy. Despite this, the deficiency was observed during the survey.
Two residents with cognitive impairment were found together in a compromising situation in a memory care unit due to inadequate supervision. One resident with severe dementia was found fully clothed in another resident's bed, while the other was undressed below the waist. Staff discovered the incident during rounds and intervened immediately. Prior to this event, neither resident had a documented history of sexually inappropriate behaviors.
A facility failed to ensure proper use of assistive devices and supervision, resulting in injuries to three residents. One resident suffered a shoulder fracture when a hospice aide repositioned her without a drawsheet. Two other residents were transferred without a transfer belt, despite needing substantial assistance. The lack of proper techniques and communication placed residents at risk of harm.
A resident with a history of aggressive behavior physically assaulted another resident, resulting in bruises and a skin tear. Despite having a care plan noting potential aggression, no new interventions were implemented after previous incidents. Staff separated the residents and assessed the injured resident, but the facility failed to prevent the abuse.
A resident with a surgically implanted intrathecal pain pump did not receive adequate pain management due to the facility's failure to obtain necessary physician orders and assist with the patient-controlled bolus for breakthrough pain. The resident's personal therapy manager device was kept out of reach, preventing self-administration of the bolus dose. Despite the resident's significant pain and repeated requests for assistance, the facility staff lacked knowledge and experience in handling the pain pump, leading to unmanaged pain for several days.
A resident with a surgically implanted pain pump was admitted to a facility without the nursing staff having the necessary competencies to manage the device. The resident, a quadriplegic with chronic pain, experienced unmanaged pain as staff were unfamiliar with the pain pump and did not provide the required support. The facility's failure to assess and ensure staff competency in managing the pain pump resulted in inadequate pain management.
The facility failed to maintain kitchen sanitation standards, as observed with dust and fuzz accumulation on air conditioning vents. Interviews revealed that while kitchen staff had cleaning duties, maintenance staff were responsible for the vents, which had not been cleaned for about six months. The Maintenance Director acknowledged a recent request for cleaning, but it was not completed. A Quality Assurance Monitor noted this issue in June 2024.
The facility failed to provide a private space for resident group meetings, holding them in an open area where staff frequently passed through. Residents felt uncomfortable voicing concerns due to the lack of privacy. The Activity Director acknowledged the issue, citing space limitations, while the Administrator was unaware of any complaints.
The facility failed to provide necessary ADL services to four residents, resulting in deficiencies in grooming and hygiene. A resident did not receive scheduled showers, leading to feelings of uncleanliness and potential skin issues. Another resident was left with oily hair and untrimmed nails due to missed showers. A third resident did not receive oral care, resulting in dirty nails and greasy hair, while a fourth resident had poor oral hygiene, leading to bad breath and dental issues. Staff interviews confirmed these lapses in care.
The facility failed to obtain physician orders for oxygen therapy for two residents, leading to deficiencies in respiratory care. One resident, with severe cognitive impairment, used oxygen without orders, and her equipment was not maintained as per protocol. Another resident, with intact cognition and multiple diagnoses, also lacked orders, and her nasal cannula was not changed regularly. Staff were unaware of these issues, and the facility's policy did not address oxygen use, contributing to the oversight.
The facility failed to maintain dialysis communication sheets and monitor post-dialysis care for several residents, leading to incomplete records and potential risks. Interviews revealed confusion and lack of adherence to protocols for handling communication sheets and monitoring vital signs, posing risks of infection and vital sign fluctuations.
Two residents in an LTC facility did not receive medications as prescribed due to errors by LVNs. One resident had multiple Exelon patches applied without removing the old ones, risking overmedication. Another resident did not receive the full dose of an intravenous antibiotic due to a partially used bag being discarded. Interviews with facility leadership confirmed expectations for adherence to physician orders and policies, but these were not met despite prior training.
A LTC facility was found to have a medication error rate of 7.41% due to two incidents. An LVN failed to remove an old Exelon patch before applying a new one on a resident with severe cognitive impairment. Another LVN did not administer the full dose of Nafcillin to a resident with sepsis, discarding a bag with 400mls remaining. Both incidents were acknowledged by the staff, highlighting a failure to adhere to medication administration policies.
The facility failed to obtain physician orders for dialysis for five residents, despite their care plans indicating regular dialysis sessions. This oversight was identified through record reviews and staff interviews, highlighting a lack of complete and accurate clinical records for residents requiring dialysis.
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. A resident on Enhanced Barrier Precautions (EBP) lacked proper signage and PPE, and staff were unaware of the need for EBP. An LVN did not don appropriate PPE while providing care to another resident on EBP. Additionally, another LVN failed to perform hand hygiene and disinfect equipment between residents, and used bare hands to separate medication, despite having attended infection control training.
The facility failed to provide full visual privacy in six resident rooms, as privacy curtains did not cover the full length of the beds, leaving gaps. A resident with moderate cognitive impairment and an indwelling catheter expressed dissatisfaction with the inadequate privacy during wound care. The facility lacked a policy to ensure proper curtain coverage.
The facility failed to maintain an effective pest control program, resulting in multiple residents being bitten by mosquitoes. One resident suffered multiple bites severe enough to cause blisters, requiring medical attention. Despite external treatments, no internal pest control measures were documented, and staff were unaware of the issue. The deficiency was identified as a PNC deficient practice.
A resident was not informed about the Medicare/Medicaid coverage and potential liability for services not covered, as the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) upon discharge from skilled services. The resident, with moderately impaired cognition and multiple medical conditions, was not notified of the option to continue services at personal cost, due to the MDS Coordinator's lack of training.
A resident's quarterly MDS assessment inaccurately indicated dialysis treatment, despite the resident not receiving such treatment following a kidney transplant. The MDS Coordinator acknowledged the error, and the acting DON confirmed the MDS Coordinator's responsibility for accurate assessments. The facility's policy on assessment frequency and timeliness was reviewed.
The facility failed to update care plans for two residents, one requiring dialysis and the other with fecal impaction. A resident with chronic kidney disease did not have dialysis included in her care plan, despite physician orders and a set schedule. Another resident's care plan did not address fecal impaction after a hospital visit, only noting incontinence. Staff acknowledged these oversights, which could lead to unmet care needs and decreased quality of life.
A resident with severe cognitive impairment and an indwelling catheter was found with his catheter bag on the floor and without a privacy cover, contrary to care plan interventions. Staff interviews revealed a lack of awareness and adherence to proper catheter care protocols, and the facility did not have a policy on catheter care or resident rights available.
A resident with a gastrostomy tube did not receive appropriate care as the facility failed to follow physician orders for flushing the tube with water before and after medication administration and bolus feeding. The resident, with a history of stroke and dysphagia, was dependent on tube feeding. LVN L did not flush the tube between liquid medications and omitted the required 100ml of water before and after bolus feeding, contrary to the facility's policy and physician's orders.
The facility failed to accurately document a facility-wide assessment, incorrectly stating there were no dialysis patients, despite having seven residents requiring dialysis. The assessment also lacked necessary contracts with dialysis providers. The DON was unaware of these inaccuracies, and the administrator delegated the assessment task to the maintenance director, who was not informed about residents' medical needs.
The facility failed to have a written agreement with a dialysis center for a resident requiring dialysis due to end-stage renal disease. Despite the resident's need for dialysis, the facility did not establish a contract with the provider, and interviews revealed a lack of awareness among staff about the necessity of such agreements. The facility also lacked a policy for coordinating with outside resources.
The facility failed to coordinate hospice services for two residents, lacking necessary physician orders for hospice admission and discharge. One resident, with acute myeloblastic leukemia and dementia, was admitted to hospice without a physician's order, risking inadequate care. Another resident was discharged from hospice without a physician's order, leading to potential service interruptions. Staff interviews confirmed the absence of orders and highlighted the risks to residents' care. The facility also lacked a hospice policy.
A resident's right to receive visitors was violated when a family member was banned from visiting due to being perceived as disruptive to staff. Despite the resident's severe cognitive impairment and history of depression, the facility's Administrator enforced the ban without a legal order, contrary to the facility's policy. The decision was supported by the resident's POA and another family member, despite advocacy efforts by the Ombudsman.
A resident's confidential information was improperly disclosed by an LVN to an unauthorized family member, and the resident's medical records were incomplete. The LVN failed to document the resident's departure against medical advice accurately and did not verify the authorization of the family member before discussing the resident's health details. The DON confirmed the documentation was insufficient and did not provide a complete account of the events.
The facility failed to ensure a safe environment by allowing sharps disposal bins on a nurse medication cart and a wound care cart to be overfilled, posing a risk to residents and staff. LVNs responsible for the carts acknowledged the hazard, and the facility's policy required monitoring to prevent overfilling.
Failure to Provide Clean, Dry Bed Linens for Incontinent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean and comfortable environment by not ensuring timely changing of urine-soaked bed linens for one resident. The resident was an adult male with diagnoses including metastatic intestinal cancer, a left kidney mass with a drainage tube, and acute kidney failure. His admission MDS showed a BIMS score of 14, indicating intact cognition, and assessments documented that he was dependent on staff for toileting hygiene, occasionally incontinent of urine, and on a diuretic. His care plan reflected an ADL self-care deficit related to functional decline and bowel and bladder incontinence. On the survey date at 11:09 AM, the resident was observed lying in bed on a draw sheet saturated with dried urine, evidenced by brown discoloration. The resident reported that his bedding had not been changed since the previous evening, that no one had checked on him that morning, and that he had not realized the bedding was wet and therefore had not notified staff. At 11:14 AM, the assigned CNA stated she had not yet checked on the resident because she had been busy with other residents and was unaware he was incontinent of urine, though she did not feel overworked and noted there were other CNAs on the hall. At 11:19 AM, the ADON stated there was no reason the resident should have been left on dirty linen and that either night shift staff or the day CNA should have identified and changed the soiled bedding during their rounds. The ADON stated the expectation that CNAs and nurses round on all residents at the beginning of their shift to assess needs and acknowledged that lying in urine-soaked linen could result in skin breakdown or irritation. Observation of the resident’s peri area and buttocks at 11:25 AM showed no skin breakdown or excoriation, with some redness from lying on his back. Interviews with other residents on the hall between 11:35 AM and 12:00 PM revealed no complaints about dirty linens and indicated staff checked on them regularly. Review of the facility’s Activities of Daily Living policy did not specifically address linen changes, though it addressed provision of care and services for bathing, dressing, grooming, oral care, and toileting.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Call Lights Were Within Reach of Residents
Penalty
Summary
Surveyors observed that the facility failed to ensure call light cords were within reach for five residents who were in their beds at the time of observation. Specifically, one resident's call light cord was stored in a bedside dresser, another's was under the mattress, and three others had their cords hanging from the light above the head of the bed. Follow-up observations confirmed that the call lights remained out of reach for these residents. Interviews with the residents revealed that several were unable to locate their call light cords, though some stated they could use the call light when needed and that it was not out of reach very often. Some residents were non-responsive to interview questions. Staff interviews, including those with an RN, CNA, LVNs, and the DON, consistently indicated that call light cords are required to be within reach of residents to allow them to call for assistance. The facility's policy on call light accessibility, dated 10/13/22, also specifies that staff must ensure call lights are within reach and secured as needed. Despite this policy and staff awareness, the observed failure to keep call lights accessible for these residents constituted a deficiency in accommodating resident needs and preferences.
Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Incident
Penalty
Summary
The facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for two residents with severe cognitive impairment residing on the memory care unit. On the date of the incident, one female resident with Alzheimer's disease and severe cognitive impairment was found fully clothed in the bed of a male resident, who was undressed below the waist. Both residents were in the male resident's room, and the event was discovered by a CNA during routine rounds. The CNA immediately intervened, separated the residents, and called for nursing assistance. Record reviews indicated that the female resident had a history of wandering behaviors and severe cognitive impairment, as reflected by a BIMS score of 00. The male resident, while having a BIMS score indicating intact cognition, had diagnoses including unspecified dementia with agitation and schizophrenia. Prior to this incident, neither resident had documented sexually inappropriate behaviors in their care plans. Staff interviews confirmed that the incident was the first of its kind for both residents, and the intent behind the interaction was unknown. The facility's failure to provide adequate supervision allowed the female resident to wander into the male resident's room and resulted in both residents being found in a compromising situation. Staff were unable to specify when the residents were last seen prior to the incident, and the event was only discovered during routine staff rounds. The incident placed residents at risk for abuse, as noted in the report.
Failure to Use Assistive Devices and Supervision Leads to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for three residents. Resident #3, who had severe cognitive impairment and was dependent on staff for transfers, suffered a displaced humeral neck fracture when Hospice Aide K repositioned her in bed without using a drawsheet. The aide lifted the resident under her armpits, resulting in a loud crack and subsequent pain. The resident's care plan required extensive assistance for transfers, and the improper handling led to the injury. Additionally, the facility did not ensure the use of a transfer belt for Residents #4 and #5 during transfers. Hospice LVN BB and Hospice Aide CC performed transfers without using a transfer belt, despite the residents' care plans indicating they required substantial/maximal assistance for chair/bed-to-chair transfers. Both residents had cognitive impairments and were unable to stand on their own, relying on staff for safe transfers. The lack of proper transfer techniques and failure to use assistive devices placed residents at risk of serious harm. The facility's oversight in ensuring hospice staff were adequately trained and informed about the residents' care plans contributed to these deficiencies. The incidents highlight the need for consistent communication and adherence to care protocols to prevent accidents and injuries.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident physically assaulted him. The incident involved two residents, both with cognitive impairments and behavioral issues. Resident #1, a male with dementia, diabetes, and bipolar disorder, had a history of physical and behavioral symptoms directed toward others. His care plan noted a potential for physical aggression, but it did not reflect any new interventions following previous incidents. Resident #2, also a male with Alzheimer's and other cognitive impairments, was dependent on staff for assistance due to his cognitive and physical limitations. On the day of the incident, Resident #1 and Resident #2 were involved in a verbal altercation in the dining room, which escalated when Resident #1 hit Resident #2 on both arms with a closed fist. This resulted in bruises and a skin tear on Resident #2. The altercation was witnessed by LVN D, who separated the residents and assessed Resident #2's injuries. Resident #1 refused to be assessed. The facility's records indicated that Resident #1 had previously exhibited aggressive behavior, but there were no new interventions in place to address this risk. The facility's policy on abuse, neglect, and exploitation was in place to protect residents, but the incident revealed a failure to implement effective measures to prevent resident-to-resident abuse. Staff interviews indicated that they were aware of the procedures to separate residents during altercations and report incidents, but there was no indication that specific strategies were in place to prevent such incidents from occurring. The lack of updated interventions in Resident #1's care plan following previous aggressive behavior contributed to the deficiency in protecting Resident #2 from abuse.
Failure in Pain Management for Resident with Intrathecal Pain Pump
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a surgically implanted intrathecal pain pump. Upon admission, the facility did not obtain the necessary physician orders for the pain pump, which was crucial for the resident's immediate care and needs. Despite the resident's repeated requests for assistance with the patient-controlled bolus for breakthrough pain, the facility did not facilitate the administration of the bolus dose from the pain pump. The resident's personal therapy manager device, which was needed to self-administer the bolus dose, was kept out of reach, preventing the resident from managing her pain effectively. The resident, who was cognitively intact and had a history of neuromuscular dysfunction, osteoporosis, quadriplegia, and pressure ulcers, experienced significant pain ranging from 6 to 8 out of 10 on the pain scale. Despite this, the facility's staff did not conduct a proper pain assessment or evaluate the resident's pain levels upon admission. The facility's medical director and nursing staff were unaware of the pain pump's functionality and did not seek guidance from the pain management physician. Instead, the facility PCP suggested oral Dilaudid for breakthrough pain, which the resident declined due to concerns about potential overdose and against her pain management doctor's advice. Interviews with the facility staff revealed a lack of knowledge and experience in handling the resident's pain pump. The staff did not conduct a self-administration medication assessment to determine the resident's capability to self-administer the bolus dose. The facility's policies on physician visits, self-administration of medications, and pain management were not followed, leading to the resident experiencing unmanaged pain for several days. This deficiency was identified as an immediate jeopardy situation, indicating a serious breach in the standard of care expected in managing residents' pain effectively.
Removal Plan
- Resident #1 was assessed for signs and symptoms of pain by the Licensed Nurse - her pain level was a 6. After medication administration, pain level assessed as effective.
- Order for prn bolus is every 6 hours was entered in the PCC orders.
- Self-Administration of meds was completed for resident involved.
- Pain care plan was updated by DON/ designee. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management.
- All residents have been evaluated for pain. All residents' pain needs are being met.
- Director of Nursing or designee educated the licensed nurses on the following educational components: Medication orders need to include; name of medication, dosage, frequency of administration and route.
- Pain Management includes evaluation of pain and administering medication as ordered by the attending physician.
- If a medication is unavailable and you can obtain from E-Kit.
- Nursing staff training on use of implanted pain pump use.
- Completion of the self-administration of medication evaluation.
- All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift.
- Education will continue until all Licensed Nurses have completed the required education.
- The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents.
- Newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents.
- Director of Nursing educated by the regional clinical specialist.
- Administrator educated by the regional clinical specialist.
- The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders.
- An Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal.
- The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented.
- The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday.
- Trends will be presented and discussed in the monthly QAPI meeting for three months.
Deficiency in Pain Pump Management for Resident
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary knowledge, competencies, and skill sets to provide care for a resident with an intrathecal pain pump. Prior to admission, the facility did not assess whether the nursing staff could meet the needs of the resident, who was a quadriplegic with chronic pain and at risk for Autonomic Dysreflexia. The resident required specialized care due to a surgically implanted pain pump that delivered medication directly to the spinal cord. The facility did not provide adequate training or assess the nursing staff's performance in managing the resident's pain pump, leading to a lack of proper pain management. The resident, who was cognitively intact, was admitted with several medical conditions, including neuromuscular dysfunction of the bladder, osteoporosis, quadriplegia, and stage 4 pressure ulcers. Despite the resident's complex medical needs, the facility's staff were not informed or trained on how to manage the pain pump. The resident reported experiencing unmanaged pain and requested assistance with the bolus dose from the pain pump, but the nursing staff were unfamiliar with the device and did not provide the necessary support. The facility's PCP was also unaware of the pain pump's functionality and offered alternative oral pain medications, which the resident declined due to concerns about potential overdose. Interviews with the nursing staff revealed that they were not trained or experienced in handling pain pumps, and the facility's DON admitted to not knowing about the resident's pain pump prior to admission. The facility's failure to assess and ensure the competency of its nursing staff in managing the resident's pain pump resulted in inadequate pain management and placed the resident at risk for serious complications. The facility's policies and procedures did not adequately address the specific needs of residents with implanted pain pumps, leading to a deficiency in care.
Removal Plan
- Resident #1 was assessed for signs and symptoms of pain by the Licensed Nurse - her pain level was a 6. After medication administration, pain level assessed as effective.
- Order for prn bolus is every 6 hours was entered in the PCC orders.
- Self-Administration of meds was completed for resident involved.
- Pain care plan was updated by DON/ designee. Included signs and symptoms of medication side effects, pain medication therapy, chronic pain, pain pump management.
- No other residents in the center have a pain pump.
- All residents have been evaluated for pain. All residents' pain needs are being met. No other residents were identified as affected by failure to manage residents' pain.
- Director of Nursing or designee educated the licensed nurses on the following educational components: Pain Management includes evaluation of pain and administering medication as ordered by the attending physician.
- If a medication is unavailable and you can obtain from E-Kit.
- Nursing staff training on use of implanted pain pump use.
- Completion of the self-administration of medication evaluation.
- The regional clinical specialist educated the director of nursing and admissions director for reviewing preadmission screening and admission documents as much as they are available prior to admission.
- All Licensed Nurses will be educated by the Director of Nursing and/ or designee prior to working their next shift. Education will continue until all Licensed Nurses have completed the required education. The Licensed Nurses that are PRN (as needed) and/or out on FMLA/LOA will have the education completed prior to working their next scheduled shift before providing care to residents. Newly hired Licensed Nurses will receive this training during orientation prior to providing care to the residents.
- Director of Nursing educated by the regional clinical specialist. Administrator educated by the regional clinical specialist. The training will include the above-stated educational components.
- The Director of Nursing and/ or designee will review new admissions in the morning clinical meeting to review new admission and reconcile new admission orders. Education provided by the regional clinical specialist.
- An Ad Hoc QAPI meeting was held with the Medical Director, facility Administrator, Director of Nursing, and Regional Clinical Specialist to review the IJ Template and the Plan for Removal.
- The Director of Nursing/ designee will review new admissions for residents that may have implanted pain pumps to ensure necessary assessment, orders, notifications, and care plans are implemented.
- The Director of Nursing will monitor to ensure the process is in place daily (Monday-Friday) for three months, and the weekend supervisor on Saturday and Sunday. Education provided by regional clinical specialist. Trends will be presented and discussed in the monthly QAPI meeting for three months.
- The administrator will ensure that the director of nursing and the admissions coordinator are reviewing preadmission screening and admission documents prior to admission to ensure that medication orders / equipment / DME are available upon admission for resident condition.
Kitchen Sanitation Deficiency Due to Unclean Air Vents
Penalty
Summary
The facility failed to maintain kitchen sanitation standards by not ensuring that food items were kept away from potential airborne contaminants, specifically dust and fuzz on the ceiling vents. During an observation, it was noted that ten air conditioning vents in the kitchen had accumulated fuzz and dust. Interviews with the Dietary Aide, kitchen staff, and the Food Service Supervisor revealed that while kitchen staff had daily cleaning assignments, the maintenance staff were responsible for cleaning the air vents. However, there was a lack of clarity and recall regarding when the vents were last cleaned, with the Food Service Supervisor indicating it was about six months ago. The Maintenance Director acknowledged that the kitchen air vents were to be cleaned by both kitchen and maintenance staff, but he could not recall the exact date of the last cleaning. He mentioned that a request had been made a couple of weeks prior, but it had not yet been completed. A review of the facility's Quality Assurance Monitor from June 2024 indicated that the ceiling vents were noted as a requirement that was not met. The facility's policy and the Federal Food Code 2022 both emphasize the importance of maintaining cleanliness in food service areas, including keeping non-food-contact surfaces free of dust and debris.
Failure to Provide Private Space for Resident Meetings
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly group meetings, affecting 10 out of 10 confidential residents reviewed for the resident council. The meetings were held in an open middle area upstairs, which was not private, as confirmed by the Activity Director. The only alternative space, the conference room, was occupied by the survey team. During a confidential resident group meeting, it was observed that the meeting took place in the activity/dining room, which was not adequately closed off from surrounding offices and hallways. Multiple staff members walked through the area, and no signs were posted to indicate a confidential meeting was in progress. Residents expressed feeling intimidated and uncomfortable discussing concerns due to the lack of privacy. The Activity Director, who had been employed at the facility for several years, acknowledged the need for a private space for these meetings but cited difficulties in accommodating residents with mobility devices in the conference room. The Administrator stated that the meetings were supposed to be held in the conference room and had not received any complaints from residents about the lack of privacy. However, the resident council minutes did not reflect any requests for a private area. The facility was unable to provide policies regarding resident rights, privacy, and resident council upon request.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to four residents, leading to deficiencies in maintaining good nutrition, grooming, and personal and oral hygiene. Resident #334, a male with intact cognition, was not given showers as scheduled despite being dependent on staff for bathing. He reported feeling dirty and had not been offered a shower since admission, with no documentation of refusals. Staff interviews confirmed the lack of showers and the potential risk of skin breakdowns due to this oversight. Resident #386, also with intact cognition, did not receive scheduled showers, resulting in oily hair, untrimmed nails, and unshaven facial hair. Despite expressing a desire for a shower, the resident remained in the same clothing and bedding over several days. Staff acknowledged the failure to provide adequate ADL care, which could lead to infections and dignity issues. The responsibility for ensuring showers and grooming was not adequately fulfilled by the aides and nursing staff. Resident #88, a female with intact cognition, did not receive assistance with oral care, resulting in long, dirty nails and greasy hair. She reported never having her nails trimmed by staff and was unaware of facial hair growth. Similarly, Resident #109, with severely impaired cognition, did not receive proper oral hygiene care, leading to bad breath and white buildup on her teeth. Staff interviews revealed a lack of consistent oral care, with potential risks for infection and health decline. The facility's policy on ADLs emphasized the importance of maintaining residents' abilities, but these failures highlighted significant lapses in care.
Failure to Obtain Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents, as they did not obtain physician orders for oxygen therapy. Resident #32, a severely cognitively impaired female with diagnoses including obstructive uropathy and dementia, was observed using oxygen without a physician's order. Her care plan indicated the use of oxygen therapy, but there were no corresponding physician orders. Additionally, her oxygen humidifier bottle was empty, and the nasal cannula had not been changed as per the facility's protocol. The nursing staff, including an LVN and the ADON, were unaware of the lack of orders and acknowledged the oversight. Resident #88, a female with intact cognition and diagnoses such as COPD and heart failure, also received oxygen therapy without a physician's order. Her care plan included oxygen use, but no active orders were found. Observations revealed a discolored and undated nasal cannula, and the oxygen level was set higher than the care plan specified. The LVN responsible for her care confirmed the absence of orders and the risk posed by not changing the nasal cannula regularly. The ADON and Acting DON were informed of the issue, acknowledging the need for physician orders and regular equipment maintenance. The facility's policy on oxygen safety did not address the use of oxygen, contributing to the oversight. Interviews with nursing staff and administration highlighted a lack of awareness and adherence to protocols for obtaining physician orders and maintaining oxygen equipment. This deficiency in respiratory care practices placed residents at risk for respiratory infections and ineffective treatment.
Failure to Maintain Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to maintain proper dialysis communication sheets for several residents, which could place them at risk of inadequate post-dialysis care. Specifically, the records for Resident #30 showed missing communication sheets for multiple dates in July 2024. Interviews revealed confusion about the process for handling these sheets, with the Director of Medical Records stating they were to be left at the nurse's station, contrary to the RN's understanding that they were to be scanned into the electronic health record (EHR). Resident #75's records also lacked physician orders for dialysis and monitoring of the port site or pre and post-dialysis vitals. Only one communication form was found, and post-dialysis assessments were not completed. The resident confirmed his dialysis schedule and the process of taking a folder to and from dialysis, but there was no evidence of consistent monitoring or documentation by the facility staff. Similarly, Resident #88 and Resident #136 had incomplete records and missing communication forms. Resident #88's care plan noted a history of refusing dialysis, leading to hospitalizations, yet there were no physician orders for dialysis or monitoring. Resident #136's care plan did not include dialysis, and communication forms were sporadic. Interviews with the ADON and Acting DON highlighted a lack of awareness and adherence to protocols for monitoring and documenting post-dialysis care, posing risks of infection and vital sign fluctuations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for two residents. For one resident, a Licensed Vocational Nurse (LVN) did not follow physician orders when administering an Exelon transdermal patch. The nurse was observed applying a new patch without removing an old patch that had been on the resident's skin for several days. This oversight was acknowledged by the LVN, who admitted to not lifting the resident's blouse to check for previous patches, which could lead to overmedication and skin irritation. In another instance, a different LVN did not adhere to physician orders for administering an intravenous antibiotic to a newly admitted resident with sepsis. The LVN was observed discarding a partially used bag of Nafcillin Sodium, resulting in the resident not receiving the full prescribed dose. The LVN was aware of the requirement to administer the entire dose but failed to notify the physician or Director of Nursing (DON) about the discrepancy. This failure was recognized as a medication error that could affect the effectiveness of the treatment. Interviews with the Assistant Director of Nursing (ADON) and the acting DON revealed that the facility's expectations were for nurses to follow physician orders and facility policies to ensure residents receive the correct medication dosages. The facility had conducted in-service training on medication administration, but the deficiencies indicated a lapse in adherence to these protocols. The facility's policies on medication administration were reviewed, highlighting the need for proper procedures to be followed to prevent such errors.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 7.41%, exceeding the acceptable threshold of 5%. This was due to two specific incidents involving two licensed vocational nurses (LVNs). The first incident involved LVN F, who failed to remove an old Exelon patch from a resident before applying a new one. This resident, who had severe cognitive impairment due to Parkinson's disease and vascular dementia, was found with two patches on her back, one of which was several days old. LVN F admitted to not lifting the resident's blouse to check for old patches on previous days, which led to the oversight. The second incident involved LVN K, who did not administer the full prescribed dose of Nafcillin to a resident with sepsis. LVN K discarded a bag of medication with 400mls remaining and replaced it with a new one, resulting in the resident not receiving the full 12g dose as ordered. Despite being aware of the issue, LVN K did not notify the doctor or the Director of Nursing (DON) about the incomplete administration. This oversight was acknowledged by both LVN K and the Assistant Director of Nursing (ADON), who confirmed that the resident was not receiving the full dose as per the physician's orders. Interviews with the acting DON and ADON revealed that the facility's expectation was for nurses to follow physician orders and ensure complete medication administration. The facility had policies in place for both parenteral and transdermal medication administration, which included steps to prevent such errors. However, the failure to adhere to these policies resulted in the medication errors observed during the survey.
Failure to Obtain Physician Orders for Dialysis
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for five residents who required dialysis. Specifically, the facility did not obtain physician orders for dialysis for these residents, which is a critical component of their medical care. This deficiency was identified through a combination of record reviews, interviews, and observations. The absence of physician orders for dialysis was noted for residents who had been receiving dialysis regularly, as indicated in their care plans and MDS assessments. Resident #30, a female with kidney failure, dementia, and diabetes, had been receiving dialysis three times a week, yet there was no physician order documented for this treatment. Similarly, Resident #18, a male with kidney failure, dementia, diabetes, and traumatic brain injury, also lacked a physician order for his dialysis, despite his care plan indicating regular dialysis sessions. Resident #127 had an incomplete physician order for dialysis, missing specific details such as the days and times of treatment. Additionally, Resident #88, who had chronic kidney disease and end-stage renal disease, did not have physician orders for dialysis or related monitoring, despite her care plan indicating the need for such treatment. Resident #75, a male with end-stage renal disease, also lacked physician orders for dialysis and related monitoring. Interviews with facility staff, including the ADON and Acting DON, revealed that the absence of these orders was an oversight, and they acknowledged the potential risks associated with this deficiency, such as missed dialysis sessions and inadequate monitoring of dialysis ports.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. For Resident #71, who was on Enhanced Barrier Precautions (EBP) due to an indwelling catheter, there was no signage or personal protective equipment (PPE) available outside the resident's room. Staff members, including CNA-A, were unaware of the need for EBP and entered the room without the required PPE, indicating a lack of communication and training regarding infection control protocols. In another instance, LVN L did not don the appropriate PPE, specifically a gown, while providing bolus feeding to Resident #103, who was also on EBP due to a g-tube. Despite the presence of a sign indicating the need for full PPE, LVN L only wore gloves, failing to comply with the facility's infection control policy. Interviews with staff, including the ADON and Acting DON, confirmed that the expectation was for staff to don full PPE when caring for residents with invasive devices, highlighting a gap between policy and practice. Additionally, LVN K failed to perform hand hygiene and disinfect a blood pressure cuff between residents, specifically Residents #25 and #244, during a medication pass. LVN K also used bare hands to separate medication for Resident #25, contrary to the facility's medication administration policy. Despite having attended training on infection control, LVN K admitted to forgetting the procedures, which underscores a need for reinforcement of infection control practices. These lapses in protocol could potentially lead to cross-contamination and the spread of infections among residents.
Inadequate Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident rooms were equipped to provide full visual privacy for each resident, as observed in six rooms (321, 322, 323, 324, 325, 327). This deficiency was identified through observations, record reviews, and interviews. Specifically, the privacy curtains in these rooms did not adequately cover the full length of the beds, leaving gaps that compromised the residents' privacy. This issue was highlighted during an observation of a resident who required privacy for wound care, where the curtain left a gap of 18-24 inches, exposing the resident to view from the doorway. The resident involved in the observation was a male with a history of heart attack, urinary tract infection, heart failure, and high blood pressure, who required partial assistance with activities of daily living and had an indwelling catheter. The resident expressed dissatisfaction with the inadequate privacy provided by the curtain, which had been an issue since his admission. The facility administrator confirmed that there was no existing policy to address privacy curtain coverage, further contributing to the deficiency.
Deficient Pest Control Program Leads to Mosquito Bites
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in multiple residents being bitten by mosquitoes. Four residents, identified as #93, #236, #243, and #435, reported mosquito bites, with Resident #435 suffering multiple bites on her hands, arms, neck, and face. The bites were severe enough to cause blisters, and the resident required medical attention, including the application of ointment and Betadine. Other residents also reported mosquito bites, with some observing mosquitoes in their rooms. Despite these incidents, the facility's pest control logs indicated that only external treatments for mosquitoes were conducted, with no internal treatments documented. Interviews with staff revealed a lack of awareness and communication regarding the mosquito issue. The Acting DON and the Administrator were not familiar with the situation, and the Maintenance Director stated that the facility had been treated externally for mosquitoes. However, there was no policy in place for pest control, and the facility did not conduct internal treatments. The deficiency was identified as a PNC deficient practice, indicating a failure to protect residents from mosquito bites and potential exposure to viruses spread by mosquitoes.
Failure to Provide SNFABN to Resident
Penalty
Summary
The facility failed to inform a resident, identified as Resident #89, about the Medicare/Medicaid coverage and potential liability for services not covered. Specifically, the facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to Resident #89 when he was discharged from skilled services before his covered days were exhausted. This notice is crucial as it informs residents of their option to continue services at their own expense once Medicare stops covering them. The absence of this notification could lead to residents being unaware of changes in their service coverage and potential out-of-pocket costs. Resident #89, a male with a moderately impaired cognition, was admitted with several medical conditions, including fractures and general muscle weakness. He was receiving occupational and physical therapy under Medicare Part A services. The MDS Coordinator, responsible for issuing the SNFABN, admitted to not providing the notice due to a lack of training from the previous coordinator. The facility's policy mandates that residents be informed orally and in writing about their financial responsibilities for services not covered by Medicare, which was not adhered to in this case.
Inaccurate MDS Assessment for Dialysis Treatment
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident status for one of the residents reviewed for MDS assessment accuracy. Specifically, the quarterly MDS assessment for a resident inaccurately indicated that the resident was receiving dialysis treatment, despite the resident not undergoing such treatment. The resident, who had a history of chronic kidney disease and a kidney transplant, confirmed that she had not been a dialysis patient for three years following her transplant. The care plan and physician orders for the resident also did not reflect any dialysis treatments. Interviews with the MDS Coordinator and the acting DON revealed that the responsibility for completing accurate MDS assessments lay with the MDS Coordinator. The MDS Coordinator acknowledged the error and stated that it was her responsibility to ensure the assessments were completed correctly. The acting DON, who was unfamiliar with the resident, confirmed the MDS Coordinator's role in completing the assessments. The facility's policy on assessment frequency and timeliness was reviewed, which outlined the requirements for completing standardized assessments according to the RAI Manual.
Failure to Update Care Plans for Dialysis and Fecal Impaction
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which led to deficiencies in addressing their specific medical needs. Resident #136, a female with severe cognitive impairment and chronic kidney disease, was not provided with a care plan that included her dialysis treatment. Despite having physician orders and a schedule for dialysis, her care plan was not updated to reflect this critical aspect of her care. Interviews with the resident and staff confirmed the oversight, with the Assistant Director of Nursing (ADON) and the MDS Coordinator acknowledging the omission. Similarly, Resident #103, a male with a history of stroke and dysphagia, was not provided with a care plan addressing fecal impaction following a hospital visit. His care plan only mentioned bladder and bowel incontinence without specific interventions for the fecal impaction noted in his hospital discharge summary. The MDS Coordinator and ADON recognized that the care plan should have been updated to include this condition, but it was missed due to the absence of the assigned MDS Coordinator. The facility's policy requires comprehensive care plans to be developed and updated to meet residents' medical, nursing, and psychosocial needs. However, the failure to update these care plans as per the policy could lead to residents not receiving necessary care and services, potentially decreasing their quality of life. The Acting DON confirmed that it is the responsibility of the MDS Coordinators to complete and review care plans quarterly, with oversight from the DON.
Deficiency in Catheter Care and Resident Dignity
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in maintaining the resident's dignity and preventing urinary tract infections. The resident, who had severe cognitive impairment and required assistance with toileting, was observed with his catheter urine collection bag laying on the floor without a privacy cover. This was contrary to the care plan interventions, which specified that the catheter bag should be positioned below the bladder level and away from the entrance room door, and that it should be monitored for kinks and signs of discomfort. Interviews with staff revealed a lack of awareness and adherence to proper catheter care protocols. A CNA observed the resident without a privacy bag and took corrective action, but other staff, including an LVN and the ADON, were unaware of the issue. The DON confirmed that catheter bags should be covered and properly hung to prevent infection and maintain resident dignity. The facility did not have a policy regarding indwelling Foley catheter care or resident rights available when requested.
Failure to Follow G-Tube Flushing Protocols
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with a gastrostomy tube, leading to a deficiency in care. The resident, a male with a history of cerebral infarction, hypertension, and dysphagia, was dependent on tube feeding and water flushes as per physician orders. The care plan aimed to prevent complications related to tube feeding and maintain adequate nutritional and hydration status. However, the facility did not adhere to the physician's orders for flushing the feeding tube with water before and after medication administration and bolus feeding. During an observation, LVN L was seen preparing to administer medications and bolus feeding to the resident. Although LVN L checked the g-tube placement and residual, she failed to flush the tube with 30ml of water between liquid medications and did not provide the required 100ml of free water before and after the bolus feeding. LVN L admitted to not following the physician's orders, mistakenly believing that liquid medications did not require additional water flushing and forgetting the free water requirement for bolus feeding. Interviews with the ADON and Acting DON revealed that the facility's expectations were for staff to follow physician orders regarding flushing protocols. Both acknowledged the risk of dehydration and tube clogging if orders were not followed. The facility's policy on enteral tube medication administration emphasized the importance of flushing with water at several steps, aligning with the physician's orders that were not adhered to in this instance.
Inaccurate Facility Assessment and Lack of Dialysis Contracts
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that accurately reflected the care needs of its residents and the resources available. Specifically, the assessment inaccurately indicated that there were no dialysis patients in the facility, despite the presence of seven residents requiring dialysis. Additionally, the facility assessment did not include necessary contracts or agreements with third-party dialysis service providers, which are essential for ensuring continuous care for residents dependent on dialysis. The deficiency was highlighted through a review of records and interviews. A resident with end-stage renal disease and dementia was identified as requiring dialysis, yet the facility's assessment did not reflect this need. The Director of Nursing (DON) was unaware of the inaccuracies in the assessment and stated that the responsibility for the facility assessment and contracts lies with the administrator. The administrator admitted to delegating the assessment task to the maintenance director, who lacked knowledge of the residents' medical conditions. Furthermore, the administrator believed that contracts with dialysis centers were unnecessary, as the residents' doctors selected the centers.
Lack of Written Agreement for Dialysis Services
Penalty
Summary
The facility failed to ensure that there were written agreements with outside resources for services provided to residents, specifically for dialysis services. This deficiency was identified during a review of the facility's records and interviews with staff. The facility did not have a contract with the dialysis center for a resident who required dialysis due to end-stage renal disease. The resident, a male with unspecified dementia and a BIMS score indicating moderate cognitive impairment, had been receiving dialysis since June 2023. However, there was no formal agreement in place with the dialysis provider as of July 2024. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of awareness and understanding regarding the necessity of having contracts with dialysis facilities. The DON acknowledged the potential risk of treatment disruption without such contracts, while the Administrator incorrectly believed that contracts were unnecessary because the residents' doctors selected the dialysis centers. Additionally, the facility lacked a policy for working with outside resources, further contributing to the deficiency.
Failure to Coordinate Hospice Services
Penalty
Summary
The facility failed to designate a member of the interdisciplinary team to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for two residents who were reviewed for hospice services. The facility did not obtain a physician's order for hospice services for one resident, and for another resident, the facility failed to obtain a physician's order to discharge from hospice services. This lack of documentation and coordination could place residents at risk of receiving inadequate end-of-life care. For the first resident, the record review revealed that the resident, who had multiple diagnoses including acute myeloblastic leukemia and dementia, was admitted to hospice services but did not have a physician's order for hospice services in her records. Interviews with facility staff, including a CNA, LVN, ADON, and DON, confirmed the absence of the necessary order and highlighted the importance of having such an order for communication and continuity of care. The staff expressed concerns about the potential risks to the resident if a change in condition occurred without the hospice being informed. For the second resident, the record review showed that the resident was initially on hospice services but was no longer receiving them. However, there was no physician's order to discharge the resident from hospice services. Interviews with facility staff revealed that the hospice company was unable to re-certify the resident for services, and there was a lack of communication regarding the discharge. The absence of a discharge order could lead to interruptions in services and potential risks to the resident's care. Additionally, the facility did not have a hospice policy in place, as confirmed by the DON.
Violation of Resident Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of their choosing, leading to a deficiency in resident rights. A male resident, who was severely cognitively impaired and had a history of depression and social isolation, was denied visits from a family member. This decision was made by the facility's Administrator after an incident involving the removal of clothing bought by the family member. Despite the family member's regular visits and care for the resident, they were banned from the facility due to being perceived as disruptive to staff, although there was no evidence of harm or threat to residents. The facility's policy stated that residents should have immediate access to family members unless the resident denies or withdraws consent. However, the Administrator enforced a ban on the family member without a criminal trespass or protective order, contrary to the facility's policy. The decision was supported by the resident's POA and another family member, despite the Ombudsman's attempts to advocate for the family member's visitation rights. The Director of Nursing acknowledged that the facility could not limit visitation without legal orders, highlighting a failure to adhere to the established policy.
Breach of Confidentiality and Incomplete Documentation
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain complete and accurate medical records for a resident. On November 23, 2023, an LVN discussed the resident's medical conditions with a family member who was not authorized to receive such information. This breach of confidentiality was captured in a video where the LVN was recorded discussing the resident's private health information in detail with an unauthorized individual. Additionally, the LVN failed to accurately document the resident's disposition after she left the facility against medical advice (AMA), as well as the events leading up to her departure. The documentation was incomplete, lacking details about who called 911, the nurse practitioner's orders, and the resident's mode of departure. The resident, who had a history of sternum fracture, multiple falls, heart attack, heart disease, and diabetes, expressed frustration with the care provided and left the facility with her boyfriend. The Director of Nursing (DON) reviewed the LVN's documentation and confirmed it did not provide a complete picture of the events. The DON also noted that the LVN did not verify if the family member was authorized to receive the resident's information, which posed a risk of the resident's HIPAA information being misused. The facility's policy requires accurate and complete documentation of each resident's experiences, which was not adhered to in this case.
Failure to Maintain Safe Sharps Disposal Practices
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accident hazards due to overfilled sharps disposal bins on a nurse medication cart and a wound care cart in Station Two Wing. Observations revealed that the sharps bins were filled past the marked fill line, with one bin's lid half open and sharps protruding approximately two inches past the fill line. LVN A and LVN B, responsible for the respective carts, acknowledged the hazard and admitted that the bins should not be filled past the fill line as it posed a risk to both staff and residents. Both nurses stated they had been in-serviced on sharps safety but could not recall the last training session. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the bins should never be filled past the fill line to ensure safety, and the facility's policy required monitoring to prevent overfilling. Interviews with the DON and the Administrator indicated that the facility had provided in-services on sharps safety, but the exact timing of the last training was unclear. The Administrator emphasized that staff were expected to follow the facility policy and ensure resident safety by maintaining their carts, including changing out full sharps bins. The facility's policy on sharps safety, dated 11/01/23, specified that sharps containers should not be filled beyond 3/4 full to prevent workplace injuries. Despite this policy, the failure to adhere to it placed residents at risk of exposure to contaminated sharps and potential blood-borne pathogens.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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