Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
A facility failed to ensure physician orders were in place for two residents’ non-invasive ventilation devices. One resident with sleep apnea had a BiPAP machine at the bedside and was using it without an order or documented settings, while another resident with chronic respiratory failure and emphysema had a CPAP machine at the bedside without an order or settings. Staff and the DON acknowledged the orders should have been present, and the care plans did not consistently reflect the device use.
Failure to include a resident and POA in quarterly care plan conferences. A male resident with stroke and impaired cognition had a care plan addressing dementia, decision-making impairment, and memory loss, but the last documented care conference was months earlier and no quarterly meetings were documented for the prior year. The POA said she was involved in care but had not had a care plan meeting in a long time, while the SW admitted a meeting had been overlooked; the DON and ADON stated care plan meetings should be held quarterly and with family.
Failure to care plan a resident’s preference for self-care with his colostomy. A resident with colostomy status, severe cognitive impairment, and assistance needs for toileting hygiene stated he had managed his own ostomy care for more than 20 years and did not want staff help. The care plan addressed colostomy care tasks but did not include his self-care preference, and the ADON, MDS Coordinator, LVN, and DON all acknowledged the preference should have been care planned.
A resident with stroke and impaired cognition did not have his comprehensive care plan reviewed and revised by the IDT after a quarterly MDS assessment. The record showed the last documented care conference was months earlier, while the POA said she had not had a care plan meeting in a long time and wanted one to discuss concerns. The SW later said the missed meeting was overlooked, and the DON and ADON confirmed care plan meetings should occur quarterly and as needed with family.
A resident with vascular parkinsonism, PVD, polyneuropathy, and dementia did not receive needed foot care, and his toenails were observed long and curving in on both feet. He stated he had been asking to see podiatry for months, while staff gave conflicting accounts about who was responsible for nail care and referral, and podiatry records showed he had not been seen.
An ADON administered multiple crushed meds via a resident’s G-tube without flushing between each medication and without checking for residual before administration. The resident had a stroke history and received nutrition via feeding tube. The DON stated the facility expected flushing before, between, and after med administration and aspiration to verify placement and residual, and the facility policy required flushing 5-10 mL of warm water between each medication and checking gastric content for residual feeding.
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.
Missing Physician Orders for BiPAP and CPAP Use
Penalty
Summary
The facility failed to ensure physician orders were in place for the use of two residents’ non-invasive ventilation devices. One resident was admitted with obstructive sleep apnea, quadriplegia, and morbid obesity, had a BIMS score of 15, and required substantial assistance with ADLs. His care plan dated 07/21/25 identified altered respiratory status related to sleep apnea and included use of a BiPAP machine on home settings, but the physician orders did not include an order for BiPAP or the settings to use. During observation, the resident had a BiPAP machine and face mask at the bedside and stated he had been using it since admission, that it was his from home, and that staff helped clean the mask about once a week. A second resident was admitted with chronic respiratory failure, emphysema, and morbid obesity, also had a BIMS score of 15, and required substantial assistance with ADLs. Her care plan addressed oxygen therapy and shortness of breath with nasal cannula use, but it did not include CPAP. The physician orders contained no order for CPAP or settings, even though a CPAP machine was observed at the bedside. The resident stated the machine was not hers, that someone brought it after admission, and that she had used one at home. Staff interviews confirmed nurses cleaned the mask weekly and assisted with application, and the DON stated there should have been a physician order and care plan entry for CPAP.
Failure to Include Resident Representative in Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to provide Resident #14 and the resident’s responsible party the opportunity to participate in the development and implementation of the resident’s person-centered plan of care through quarterly care plan conference meetings. Record review showed the resident was a male admitted to the facility with diagnoses including stroke, and the care plan addressed impaired cognitive function/dementia, difficulty making decisions, impaired decision making, and long- and short-term memory loss. The resident’s last documented care plan meeting was on 08/02/24, and the record reflected no documented quarterly care plan conference meetings for the last 12 months. The resident’s progress notes showed the last social work documentation related to a care conference was a telephone care conference on 08/02/24 with the SWA, ADON, and the resident’s spouse. During interview, the resident’s POA stated she was very involved in the resident’s care but had not had a care plan meeting in a very long time and could not recall the last one. The Social Worker stated the resident’s care plan meetings were usually held by phone, but she could not recall the exact date of the last meeting and acknowledged there was no care plan meeting in May 2025; she stated it had been overlooked. The DON and ADON B stated care plan meetings should be completed quarterly and as needed with family, and the facility’s comprehensive care plan policy stated the resident and resident’s representative were to be included to the extent practicable.
Failure to Care Plan Resident’s Ostomy Self-Care Preference
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #74 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #74’s quarterly MDS assessment dated 07/18/25 showed he was an [AGE] year-old male admitted with diagnoses including colostomy status, vascular parkinsonism, hypertension, polyneuropathy, and non-Alzheimer’s dementia. His BIMS score was 08, indicating severe cognitive impairment, and he required supervision or touching assistance with toileting hygiene, including ostomy-related hygiene. The care plan revised 07/07/25 addressed alteration in gastrointestinal status related to colostomy status and included interventions such as changing the colostomy bag as needed, cutting the wafer to fit around the stoma as needed, and colostomy care each shift and as needed. However, it did not address Resident #74’s stated preference to complete his own ostomy care. During interviews, Resident #74 stated he had performed his own ostomy care for more than 20 years and did not like anyone helping him. The ADON, MDS Coordinator, LVN, and DON each acknowledged that the resident preferred to do his own ostomy care and that this preference should have been care planned, but it was not.
Failure to Review and Revise Care Plan After Assessment
Penalty
Summary
The facility failed to ensure Resident #14’s comprehensive care plan was reviewed and revised by the interdisciplinary team after the quarterly MDS assessment completed on 05/10/25. The resident was a [AGE]-year-old male admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including stroke. The care plan in the record, dated 05/12/25, addressed impaired cognitive function/dementia and included an intervention to communicate with the resident’s family/caregivers regarding his capabilities and needs. Record review showed the last documented care conference for Resident #14 was on 08/02/24, when a telephone care conference was held with the SWA, ADON, and the resident’s spouse. The resident’s POA stated she had not had a care plan meeting in a very long time and wanted one to address concerns. The Social Worker stated care plan meetings were usually held by phone, said the last meeting was either June or July 2025, and later acknowledged there was no care plan meeting for May 2025 and that the omission was overlooked. The DON and ADON B stated care plan meetings should be completed quarterly and as needed with family, and ADON B confirmed the last documented care plan conference in the record was August 2024.
Failure to Provide Needed Foot Care and Toenail Trimming
Penalty
Summary
Provide appropriate foot care was not ensured for Resident #74, a male resident with diagnoses including vascular parkinsonism, hypertension, polyneuropathy, non-Alzheimer's dementia, and colostomy status. His quarterly MDS reflected a BIMS score of 08 and need for partial/moderate assistance with personal hygiene. His care plan for peripheral vascular disease included interventions to educate him on proper foot care, including keeping toenails cut, but the facility's podiatry visit records for March 2025 through August 2025 showed he had not been seen by the podiatrist. On 08/20/25, the resident was observed in a wheelchair and stated he had been waiting for staff to assist him with putting on his socks. Observation showed the third and fourth toenails on both feet were long and curving in, and he stated he had been asking to see a podiatrist since May 2025. Staff interviews reflected differing understanding of who was responsible for nail care and podiatry referral, and the ADON stated she had asked the Social Worker for a podiatry referral on 05/15/25 but the resident had not been seen. The Social Worker stated she had just received a podiatry referral on 08/21/25 and had not received one before that date. The DON stated she was made aware of the resident's toenails on 08/21/25 and that residents' nails needed to be trimmed for comfort.
Failure to Flush and Check Residual During G-Tube Medication Administration
Penalty
Summary
Pharmaceutical services were not provided in accordance with the facility’s medication administration policy for a resident who had diagnoses including stroke and received nutrition via a feeding tube. The resident’s August 2025 physician orders included enteral feeding instructions and directions to check placement of the gastrostomy tube by observing the external length or marking at the exit site and by observing for an increase in gastric aspirate volume. There were no orders for flushing the gastrostomy tube between medication administrations. During observation on 08/20/2025, an ADON prepared multiple medications for administration through the resident’s gastrostomy tube, crushed the medications, and mixed them with water. She administered the medications one at a time after flushing the tube with 30 mL of water, but did not flush the tube between each medication. She also did not check for residual before administering the medications. In interview, the ADON stated she was aware of the need to flush between medications and to check residual before administration, but forgot to do so. The DON stated the expectation was to flush before, between, and after medication administration and to aspirate to verify placement and residual before giving medications. The facility’s medication administration policy stated to flush with 5-10 mL of warm water between each medication and to check gastric content for residual feeding.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Terrace Healthcare Center Of Fort Worth | 0.3 mi | ★★★★★ | 7 | 0 |
| Ignite Medical Resort Fort Worth, Llc | 0.9 mi | ★★★★★ | 17 | 0 |
| Mira Vista Court | 1.2 mi | ★★★★★ | 2 | 0 |
| Wedgewood Nursing Home | 1.2 mi | ★★★★★ | 16 | 0 |
| Ft. Worth Southwest Nursing Center | 1.8 mi | ★★★★★ | 6 | 0 |
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