Downtown Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 424 S Adams St, Fort Worth, Texas 76104
- CMS Provider Number
- 455651
- Inspections on file
- 55
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Downtown Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, frequent incontinence, and intact cognition, who required assistance and supervision for bathing, was not provided scheduled showers on designated shower days. Over a multi‑day period, showers were documented as not applicable and there was no record of bathing, while the resident reported going several days without a shower after a CNA stated she ran out of time and did not offer an alternative. The CNA acknowledged not coordinating with other staff or notifying nursing, despite adequate staffing, and facility leadership confirmed that residents are expected to receive showers at least twice weekly in accordance with their care plans and resident rights.
A CNA engaged in verbally abusive behavior by calling a resident with moderate cognitive impairment a derogatory name after the resident used inappropriate language. The incident was overheard by HR staff, and the CNA did not deny the behavior when questioned. The resident's care plan required staff to avoid reacting to negative behavior, but this was not followed.
Staff failed to immediately report a resident's allegation of abuse and neglect to the facility's Abuse Coordinator as required by policy. The incident involved a resident with paraplegia who alleged that a CNA attempted to choke him after he was left waiting for incontinence care. Multiple staff members were informed of the allegation, but none reported it within the required timeframe, and no injuries were observed.
A resident's discontinued Diazepam remained in the medication cart on the memory care unit, with incomplete documentation and failure to follow facility procedures for removal and destruction. Nursing staff and the DON confirmed that discontinued medications should be promptly removed and properly documented, but these steps were not followed.
A resident with hypertension and other chronic conditions was given Lisinopril and Metoprolol by nursing staff on multiple occasions, even though their blood pressure readings were below the physician-ordered parameters for holding these medications. Medication administration records showed that both medications were administered outside the prescribed limits, and interviews with the DON and Administrator confirmed that this was not in accordance with physician orders or facility policy.
A resident with multiple chronic conditions and moderate cognitive impairment repeatedly refused essential care and services, including wound care, medication, and showers. The facility's care plan did not include interventions to address these refusals, despite documentation of ongoing issues and facility policy requiring such measures. Interviews with the DON and Administrator confirmed that these refusals were not properly addressed in the care plan.
A Treatment Nurse failed to follow infection control protocols by placing a contaminated gloved hand into a package of clean gauze during wound care for a resident with chronic wounds, then returning the package to the treatment cart for future use. This action was observed and acknowledged by facility leadership as a breach of infection control policy.
A resident with multiple chronic conditions, including malnutrition and end stage renal disease, experienced a significant weight loss of nearly 26% over four months. Despite care plans identifying the risk, staff did not consistently monitor or intervene, and the resident was not included in the facility's red cup program for at-risk individuals. Communication gaps and lack of follow-through on dietary recommendations contributed to the deficiency.
A resident with significant fall risk factors experienced a fall, but the responsible LVN did not complete the required fall assessment or implement new interventions as mandated by facility policy. Although initial notifications and neuro checks were performed, the assessment was delayed, and the care plan was not updated in a timely manner, resulting in a lapse in supervision and accident prevention.
A resident receiving hospice care and requiring oxygen and nebulizer treatments was found with nasal cannula tubing on the floor, an undated humidifier bottle, and an unbagged nebulizer mask. Staff interviews confirmed that respiratory equipment should be clean, dated, and properly stored, in accordance with facility policy and professional standards. These lapses resulted in a failure to provide safe and appropriate respiratory care.
A resident with a known history of physical and verbal aggression attacked another resident, causing a serious eye injury that required hospitalization and surgery. Despite ongoing behavioral issues and interventions such as medication adjustments and psychiatric referrals, the aggressive resident remained in the unit and continued to display threatening behaviors, ultimately leading to the assault. The facility did not prevent the abuse, resulting in significant harm.
A resident with paraplegia and chronic osteomyelitis missed a scheduled dose of Vancomycin due to staffing issues at the facility. The resident reported the missed dose to the ADON, who confirmed the oversight and noted that the facility was short-staffed over the weekend. The facility's medication administration policy, which includes the right time for medication, was not adhered to.
The facility failed to secure medications in Med Room A, leaving them on a cart outside the room. An ADON left medications, including an albuterol inhaler and Afrin nose spray, unsecured, allowing residents to pass by them. The ADON admitted the oversight, acknowledging the responsibility to secure medications. The AIT confirmed that the facility's policy requires medications to be secured, and it was the DON's responsibility to ensure compliance.
The facility failed to properly label and date stored food items in the kitchen, as observed during a survey. Unlabeled and undated items, such as frozen pancakes and broccoli, were found in the walk-in freezer, and an open box of ice cream containers had ice crystal accumulation. The Dietary Manager confirmed that staff are expected to label items with the name, open date, and use-by date, as per the facility's policy and the U.S. Public Health Service Food Code.
The facility failed to provide specialized rehabilitative services for two residents, leading to a deficiency in care. One resident with multiple health issues was not screened for physical therapy despite needing it, and another resident expressed a desire to walk but only received occupational therapy for her hands. Interviews revealed systemic issues in the therapy screening process, with staff acknowledging inconsistencies and a lack of specific policies. Staffing shortages and a new Director of Rehabilitation contributed to the oversight.
A long-term care facility failed to adhere to infection control protocols, including a nurse not wearing a gown while administering medication to a resident on Enhanced Barrier Precautions, a wound care physician and ADON not wearing gowns during wound care for a resident on contact isolation, and a CNA not sanitizing hands between feeding two residents. These lapses increased the risk of infection transmission.
Two residents' dignity was compromised during a meal when a CNA yelled across the dining room and fed multiple residents simultaneously. The incident involved residents with cognitive and communication deficits, and the facility's policies on resident rights and feeding were not followed.
A resident was found smoking unsupervised in the courtyard during non-smoking times, despite the facility's policy requiring direct supervision for residents assessed as needing it. The resident, who was cognitively intact and had a history of MRSA infection and hypertension, kept his own cigarettes and lighter, unaware they should be stored at the nurse's station. Staff interviews revealed inconsistencies in enforcing the smoking policy, leading to the resident smoking unsupervised.
A facility failed to provide adequate pharmaceutical services, resulting in medication administration errors for two residents. An LVN administered Furosemide to a resident despite their blood pressure being below the prescribed parameter, and Vancomycin was given to another resident without checking the necessary trough levels. The facility's policies emphasize the importance of reviewing orders and lab results, but these were not followed, leading to the deficiencies.
A facility failed to ensure a PASRR Evaluation for a resident with mental illness after a positive Level I screening. The resident, admitted with cognitive and mental health issues, did not have a care plan addressing the PASRR findings. The administrator lacked training on the PASRR process, and the MDS Coordinator did not follow up on communications with the local authority. Although the evaluation was completed, it was not documented in the resident's records, contrary to facility policy.
A facility failed to develop a baseline care plan within 48 hours for a resident with cognitive and mental health issues, including anxiety and depression. The resident's care plan did not address his PASRR Level I for mental illness, and the facility lacked a DON, leaving care plan responsibilities to all nurses and the ADM. The MDS RN was not responsible for care plan monitoring, and the corporate nurse was assisting with clinical concerns.
The facility failed to ensure a safe environment by allowing residents to keep cigarettes and lighters on themselves and pick up cigarette butts, leading to potential burn risks. Despite care plans and policies requiring supervision and secure storage of smoking materials, residents were observed engaging in unsafe smoking practices without adequate oversight.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper foot care, as her toenails were not trimmed by a podiatrist despite being referred in April. Observations revealed thick, yellow, and curled toenails, and staff interviews indicated confusion over responsibility for nail care. The facility's outdated foot care policy lacked a clear referral process, contributing to the oversight and delay in providing necessary podiatry services.
The facility failed to provide necessary nail care for two residents, leading to deficiencies in maintaining personal hygiene. One resident with cognitive impairment and a hand contracture had long, untrimmed nails with a yellow substance, while another resident with severe cognitive impairment was observed with long fingernails. Staff interviews revealed inconsistencies in nail care responsibilities and adherence to facility policies.
The facility failed to provide scheduled showers to two residents, both requiring assistance with activities of daily living. Despite having intact cognition and no documented refusals, the residents received significantly fewer showers than scheduled. Staff interviews revealed inconsistencies in documentation and communication regarding shower refusals and completions, with unclear documentation processes contributing to the deficiency.
A facility failed to ensure a safe environment in a secured unit dining room by installing a temporary window air conditioning unit with unsecured cords, posing a hazard to residents. Staff interviews revealed awareness of the risks, especially for residents with conditions like dementia, but the temporary solution lacked adequate safety measures. The administration acknowledged the oversight, and the facility's policy emphasized the importance of a safe environment.
A facility failed to implement policies to prevent abuse and neglect when a CNA did not report an incident of alleged abuse involving a resident with Alzheimer's disease. Despite recent training, the CNA did not report the incident due to fear of retaliation. Other staff members and the Administrator were unaware of the incident until it was brought to their attention by a surveyor.
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator. A CNA did not report an incident where another CNA allegedly grabbed a resident by the neck and held him down in a choke hold. The CNA did not intervene or report the incident due to fear of retaliation and physical harm.
The facility failed to revise care plans for two residents requiring direct supervision while smoking. Both residents were found smoking unsupervised despite assessments indicating the need for supervision, placing them at risk of harm.
The facility failed to ensure adequate supervision for five residents who required supervision while smoking. Observations revealed these residents smoking without staff supervision, contrary to their care plans and safe smoking assessments. Interviews confirmed that residents often kept their own smoking materials and smoked without supervision, despite the facility's smoking policy requiring direct supervision and regular assessments.
The facility failed to provide privacy curtains for two residents while their curtains were being laundered, leaving them without privacy during personal care activities. The residents were moved back into their room after a bed bug treatment, but the curtains were not replaced, causing discomfort and lack of privacy.
The facility failed to ensure proper foot care for four residents, leading to overgrown and potentially problematic toenails. Interviews revealed inconsistencies in the approach to toenail care, with some staff stating that nurses could trim toenails while others indicated that only a podiatrist could perform this task. A review of podiatry visits showed that the residents had not been seen by the podiatrist and were not scheduled for an upcoming visit.
Failure to Provide Scheduled Showers and ADL Assistance for Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate ADL care, specifically showers, to maintain a resident’s personal hygiene as required by her care needs and facility policy. Record review showed that a cognitively intact female resident, admitted from an acute care hospital with multiple complex medical conditions including heart failure, kidney failure, diabetes, cerebrovascular accident, depression, and frequent bowel and bladder incontinence, required set-up or clean-up assistance with personal hygiene and supervisory assistance with showers/baths. Her admission MDS documented that she was independent with eating, oral hygiene, and upper body dressing, but needed assistance for personal hygiene and bathing. Review of her electronic medical record over a 20‑day look‑back period showed that showers on two specific dates were documented as “not applicable,” and there was no documentation of a shower over a three‑day span. During interview, the resident reported that earlier in the month she went multiple days without a shower because the CNA assigned to her stated she would provide the shower at the end of the shift, then later reported she had run out of time and did not provide the shower or offer an alternative opportunity. The resident stated she did not refuse care, did not report the missed showers to nursing, and felt unclean after going three days without a shower, expecting to receive one every other day. CNA A confirmed that the resident’s shower days were Monday, Wednesday, and Friday, and admitted that on the days documented as “not applicable” she simply ran out of time, despite having enough staff, and did not coordinate with other staff or notify the nurse. Facility leadership interviews confirmed that residents were expected to receive showers at least twice weekly according to their care plan and that the resident should have been offered showers on her scheduled days, consistent with the facility’s Bath and Resident Rights policies, which state that residents will receive assistance with bathing per their care plan and have a right to a dignified existence.
Verbal Abuse of Resident by CNA
Penalty
Summary
A certified nurse aide (CNA) engaged in verbally abusive behavior toward a female resident with moderate cognitive impairment and a diagnosis of a rare genetic disorder associated with intellectual disability and poor coping skills. The incident occurred when the CNA called the resident an expletive in response to the resident using inappropriate language. The exchange was overheard by the facility's human resources staff, who recognized both voices and confirmed the use of the derogatory term by the CNA. The resident later reported feeling bad after being called the name, and the CNA did not deny the use of inappropriate language when questioned by staff. The resident's care plan included interventions for staff to provide positive interactions and avoid reacting to negative behavior due to her impaired cognition and behavioral challenges. Despite this, the CNA failed to maintain professional conduct and engaged in a verbal altercation with the resident. The facility's abuse policy defined verbal abuse as the use of disparaging or derogatory language toward residents, regardless of their cognitive status. The CNA had previously received training on abuse and neglect prevention.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, as required. Specifically, staff members including two LVNs and two CNAs did not report a resident's allegation of abuse and neglect to the facility's Abuse Coordinator (the Administrator). The incident involved a male resident with paraplegia, major depressive disorder, insomnia, chronic pain, neurogenic bowel, and neuromuscular dysfunction of the bladder, who was cognitively intact and required partial to moderate assistance with toileting hygiene. The resident alleged that a CNA attempted to strangle or choke him after he confronted her about not being changed for several hours. Multiple staff interviews and record reviews revealed that the resident had his call light on for an extended period, called the front desk, and eventually wheeled himself to the nurse's station to seek assistance. When he found the CNA, a confrontation occurred during which the resident felt threatened by the CNA's actions, though no physical injuries were observed or documented. The incident was communicated to several staff members, including LVNs and CNAs, but none of them reported the allegation to the Abuse Coordinator or completed an incident report in a timely manner. The facility's policy required immediate verbal reporting of suspected abuse, neglect, or exploitation to the Abuse Preventionist or designee, with a two-hour reporting window for allegations involving abuse or serious bodily injury. Despite this, the staff involved did not follow the policy, resulting in a delay in reporting the resident's allegation. The deficiency was identified through interviews, record reviews, and examination of facility policies, which confirmed that the required immediate reporting did not occur as stipulated.
Discontinued Medication Not Removed from Medication Cart
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that discontinued medications were promptly removed from the medication cart on the memory care unit. Specifically, a resident's Diazepam, which had been discontinued by physician order, remained in the narcotic box on the secure unit medication cart well after the discontinuation date. Record reviews showed inconsistencies and incomplete documentation on the narcotic sheet, including missing dates and signatures for administered and wasted doses. Observations revealed that the discontinued Diazepam was still present in the medication cart, and the medication administration records did not reflect proper removal or destruction of the drug. Interviews with nursing staff and the DON confirmed that discontinued medications should be removed from the cart immediately and that two nurses are required to sign off on the disposal of narcotics. However, the process was not followed, and the discontinued medication was not brought to the DON as required. Facility policies reviewed indicated that discontinued medications must be marked, removed from the cart, and stored securely until destroyed, but these procedures were not adhered to in this instance.
Failure to Hold Antihypertensive Medications per Physician Parameters
Penalty
Summary
A deficiency occurred when a resident with a history of multiple sclerosis, cognitive communication deficit, essential hypertension, and a history of transient ischemic attack was administered Lisinopril and Metoprolol despite physician orders specifying to hold these medications if the resident's systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) was less than 60, or heart rate (HR) was less than 60. On four separate occasions, nursing staff administered both medications even though the resident's SBP and/or DBP were below the ordered parameters. Specifically, the medications were given when the SBP was recorded as 106, 104, and 98, and the DBP was as low as 59, all of which were outside the prescribed limits. The medication administration records confirmed that the medications were marked as given on these dates by two different nurses, both of whom no longer worked at the facility at the time of the survey. There was no documentation of adverse effects in the resident's progress notes. Interviews with the DON and Administrator confirmed that the medications should not have been administered outside the physician's parameters and that all physician orders are expected to be followed. The facility's medication administration policy also required adherence to specific monitoring and the 10 rights of medication administration.
Failure to Address Repeated Refusals of Care in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical diagnoses, including Multiple Sclerosis, Cognitive Communication Deficit, and a history of Transient Ischemic Attack. Despite the resident's moderate cognitive impairment and repeated refusals of essential care and services such as wound care, perineal care, medication administration, showers, and nutritional supplements, the care plan did not include any interventions to address these refusals. Documentation in the resident's progress notes showed numerous instances where the resident declined wound debridement, application of prescribed creams, blood sugar checks, and other necessary treatments over an extended period. Interviews with the DON and Administrator confirmed that the resident's refusals should have been addressed in the care plan, with specific interventions to encourage acceptance of care. The facility's own policy required that the care plan identify declined care, the associated risks, and efforts by the interdisciplinary team to educate the resident and seek alternative solutions. However, the care plan lacked these elements, resulting in a failure to meet the resident's identified needs as outlined in the comprehensive assessment.
Failure to Maintain Infection Control During Wound Care
Penalty
Summary
A deficiency occurred when a Treatment Nurse failed to follow proper infection control procedures during wound care for a female resident with chronic venous hypertension and diabetic foot ulcers. During the wound care process, the nurse wiped the resident's toes, then placed her gloved hand—contaminated from contact with the wounds—back into a package of clean gauze multiple times. The nurse subsequently closed the package and returned it to the treatment cart for future use with other residents. This action was observed by surveyors and confirmed in interviews with the nurse, the DON, and the Administrator, all of whom acknowledged the risk of contamination and infection resulting from this practice. The resident involved had been admitted with significant risk factors for infection, including chronic venous ulcers and diabetes-related foot ulcers. The facility's infection control policy required maintaining a safe and sanitary environment to prevent the transmission of disease and infection. Despite this, the nurse's actions directly contradicted established infection control protocols, as confirmed by both her own admission and statements from facility leadership.
Failure to Prevent Significant Weight Loss in Resident with Complex Medical Needs
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a 25.96% weight loss over four months. The resident, who had multiple complex medical diagnoses including protein-calorie malnutrition, diabetes mellitus, end stage renal disease requiring dialysis, and Parkinson's Disease, was admitted on a mechanically altered diet and required setup or clean-up assistance with eating. Despite being identified as at risk for unplanned weight loss on her care plan, interventions such as monitoring weight, encouraging meal completion, and offering supplements or alternatives were not effectively implemented or documented. The resident's weight declined from 195.00 pounds to 169.40 pounds over the review period. Nutrition assessments noted significant weight loss, but the only dietary change recommended was a modification in diet texture. The resident refused several meal trays, citing dislike for the food options, particularly ground meats and salty alternatives, and expressed a preference for specific meals like chicken pot pie. The facility's red cup program, designed to alert staff to residents at risk for malnutrition, did not include this resident, and there was confusion among staff regarding responsibility for monitoring and implementing this program. Interviews with staff revealed gaps in communication and follow-through regarding the resident's nutritional needs. The dietitian was aware of the weight loss but questioned the accuracy of weights and did not consistently review dialysis weights or logs. The DON acknowledged awareness of the weight loss but did not recognize its severity until recent training and had left intervention planning to the dietitian. The CNA and LVN assigned to the resident were either unaware of the weight loss or not involved in monitoring intake. The facility's policies required more frequent weights and interventions for significant weight loss, but these were not consistently followed for this resident.
Failure to Complete Timely Fall Assessment and Interventions After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors for falls, including alcohol-induced dementia, reduced mobility, history of falling, unsteadiness, and muscle weakness, experienced a fall. The resident required supervision and assistance with several activities of daily living and had a documented fall with no injuries prior to the incident. The care plan included interventions such as keeping the call light within reach, educating on walker use, and providing environmental cues. However, after the resident's fall, a fall assessment was not completed as required by facility policy. The LVN responsible for the resident did not complete the fall assessment or implement new interventions following the fall. Although the resident was found on the floor with a twisted knee and reported pain, and appropriate notifications and neuro checks were initiated, the required fall assessment was not performed. The ADON was notified of the fall and requested the LVN to return to complete the assessment, but the assessment was delayed and not completed in a timely manner. The DON and Administrator both confirmed that assessments should be completed after every fall to ensure appropriate care and interventions are provided. Facility policy mandates that a fall risk assessment be completed after each fall, with interventions updated as indicated. The failure to complete the assessment meant that the resident did not receive a timely evaluation of her condition or updated interventions to prevent further incidents. This lapse in protocol could result in residents not having the necessary resources or supervision to ensure their safety and appropriate care.
Failure to Maintain Safe and Appropriate Respiratory Equipment Storage and Labeling
Penalty
Summary
A deficiency was identified when a resident requiring respiratory care was not provided with care consistent with professional standards of practice and the resident's care plan. During observation, the resident's nasal cannula and tubing were found on the floor, and the humidifier bottle attached to the oxygen concentrator was not dated. Additionally, a nebulizer mask was found unbagged in the resident's drawer. The resident reported receiving breathing treatments every morning but was unaware of how the equipment was stored after use. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that all respiratory equipment should be clean, dated, labeled, and properly stored when not in use. Staff acknowledged that tubing found on the floor or unbagged should be discarded and replaced, and that humidifier bottles should be dated to prevent overuse. The facility's policy also required that nasal cannulas and related equipment be stored in a treatment bag when not in use and that non-disposable humidifier bottles be changed and dated regularly. The resident involved had a history of alcohol-induced dementia, chronic pain, a benign lung neoplasm, and was receiving hospice care. The care plan included monitoring for respiratory distress, and physician orders indicated the use of oxygen therapy and nebulizer treatments. Despite these documented needs and protocols, the observed lapses in equipment storage and dating constituted a failure to provide safe and appropriate respiratory care as required.
Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect a resident from abuse by another resident, resulting in a serious injury. One resident, who had a documented history of physical and verbal aggression towards both staff and other residents, physically attacked another resident on the secure unit. The aggressive resident had previously exhibited behaviors such as yelling, name-calling, threatening, and even exposing himself in common areas. Despite these ongoing behaviors, interventions such as redirection, medication adjustments, and referrals for psychiatric consultation were documented, but the resident remained in the unit and continued to display aggressive tendencies. On the day of the incident, the aggressive resident pushed another resident, causing the victim to fall and sustain a laceration to the head and a serious injury to the right eye, which required hospitalization and surgical repair. The incident was witnessed by a staff member, who immediately called for nursing assistance. The injured resident was assessed, emergency services were contacted, and the resident was transported to the hospital for treatment. Prior to this event, the aggressive resident's care plan and progress notes reflected ongoing concerns about his behavior, including multiple documented episodes of aggression and staff interventions. The facility's policy stated that residents should not be subjected to abuse by anyone, including other residents, and outlined the need for interventions to prevent such incidents. However, despite the known risk and repeated aggressive behaviors, the facility did not prevent the assault that resulted in significant harm to another resident. The deficiency was identified as past non-compliance, with the immediate jeopardy beginning and ending on the day of the incident.
Missed Antibiotic Dose Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were accurately dispensed and administered to meet the needs of each resident, specifically for one resident who missed a dose of antibiotic medication. The resident, who was admitted with paraplegia and chronic osteomyelitis, had a physician's order for Vancomycin to be administered intravenously every 12 hours. However, the resident did not receive the scheduled 9:00 PM dose on a specific date. This oversight was discovered when the resident reported the missed dose to the ADON at 2:00 AM the following day. The ADON confirmed the missed dose and noted that the facility was short-staffed over the weekend, which contributed to the error. The nurse responsible for the resident's care had completed her shift before the scheduled dose, and the unit nurse who took over was not reachable for comment. The facility's policy on medication administration emphasizes the importance of adhering to the 10 rights of medication administration, including the right time, which was not followed in this instance.
Failure to Secure Medications in Med Room A
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with currently accepted professional standards in one of the two medication rooms reviewed. Specifically, the Assistant Director of Nursing (ADON) left medications unsecured outside Med Room A on top of a cart. These medications included four boxes of breathing treatment medication, an albuterol inhaler, Afrin nose spray, and a Geri Tussin DM cough medication bottle. During this time, residents were observed passing by the unsecured medications, which were accessible to them. The door to Med Room A was closed and locked, and the ADON was inside the room, unable to see the residents passing by due to the limited view from the med room window. In an interview, the ADON acknowledged the oversight, stating that she should have taken the cart inside Med Room A to prevent resident access to the medications. She admitted that it was her responsibility to secure medications when they were in her possession. The Administrator in Training (AIT) also confirmed that medications should be secured and stored according to facility policy, and it was the Director of Nursing's (DON) responsibility to ensure that the ADON followed the policy. The facility's policy on medication labeling, revised in April 2007, requires that all medications be properly labeled and secured, but this was not adhered to in this instance.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that stored food items were properly labeled and dated. During an inspection of the walk-in freezer, it was found that an unopened bag of pre-made frozen pancakes and a bag of broccoli were not labeled with their contents or the date they were received into the facility. Additionally, these items were not in their original packaging. An open cardboard box containing individual ice cream containers was also found with ice crystal accumulation on top, indicating improper storage. An interview with the Dietary Manager confirmed that the facility's expectation is for staff to properly close boxes and label them with the name of the item, the date it was opened, and the use-by date. The facility's Food Storage and Supplies policy, dated 2012, requires that open packages of food be stored in closed containers or sealed bags and dated when opened. The U.S. Public Health Service Food Code mandates that ready-to-eat, time/temperature control for safety food held for more than 24 hours must be clearly marked with a date to ensure it is consumed, sold, or discarded within a safe timeframe. The failure to comply with these standards could lead to cross-contamination and food-borne illness among residents.
Failure to Provide Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for two residents, leading to a deficiency in care. Resident #1, a female with a history of type 2 diabetes mellitus, transient ischemic attack, heart failure, and chronic obstructive pulmonary disease, was admitted to the facility without being screened for physical therapy, despite her care plan indicating a need for PT/OT evaluation and treatment. Similarly, Resident #111, a female with diastolic heart failure, muscle weakness, and a history of transient ischemic attack, was not screened for physical therapy, although she expressed a desire to walk and had only received occupational therapy focused on her hands. Interviews with facility staff revealed systemic issues in the screening process for therapy services. The Director of Rehabilitation (DOR), who had been at the facility for two weeks, acknowledged that the goal was to screen new admissions for therapy within 48 hours, but Residents #1 and #111 were not screened for physical therapy. The Corporate RN noted that the facility's procedures for therapy screening were inconsistent and dependent on various factors, including the payor source and changes in residents' conditions. The RN also mentioned that the facility lacked a specific policy on therapy screening, which contributed to the oversight. The Administrator in Training (AIT) confirmed that the expectation was for all residents to be screened for therapy services, but acknowledged that the new DOR and staffing shortages had impacted the facility's ability to meet this expectation. The AIT stated that morning meetings were held to identify residents who might need therapy, but the facility was currently short-staffed and rushing through work, which may have led to residents being missed. The facility's Admission/Readmission policy, dated 2003, indicated the need for an interdisciplinary plan of care, but did not specifically address therapy screening procedures.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several incidents involving staff not adhering to established protocols. In one instance, a Licensed Vocational Nurse (LVN) did not wear a gown while administering medication to a resident on Enhanced Barrier Precautions (EBP) due to a gastrostomy tube. The LVN was unaware that a gastrostomy tube required EBP and had not been trained on this aspect of infection control, leading to a lapse in protocol adherence. Another incident involved a wound care physician and an Assistant Director of Nursing (ADON) who did not wear gowns while providing wound care to a resident on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA) and other multi-drug-resistant organisms (MDROs). Although the ADON wore gloves and a mask, the lack of gowns was a breach of the contact isolation precautions. The ADON acknowledged the oversight and the importance of following isolation precautions to prevent the spread of infection. Additionally, a Certified Nursing Assistant (CNA) failed to sanitize her hands between feeding two residents, which is a critical step in preventing the transmission of infections. The CNA admitted to sometimes feeding multiple residents at once without performing hand hygiene, which contradicts the facility's policy on hand washing and feeding procedures. These failures collectively placed residents at an increased risk of exposure to communicable diseases and infections.
Violation of Resident Dignity During Meal Service
Penalty
Summary
The facility failed to uphold the dignity and rights of two residents during a breakfast meal. CNA C was observed feeding two residents simultaneously and yelled across the dining room at Laundry Aide D, disrupting the meal environment. This incident involved Resident #59, who had major depressive disorder and cognitive communication deficits, and Resident #88, who had cognitive communication deficits, dysphagia, and legal blindness. Both residents were dependent on staff for eating and had care plans that emphasized the need for calm communication and protection of their rights. During the incident, Laundry Aide D stood over Resident #88 while conversing with CNA C about social matters, further compromising the residents' dining experience. Interviews with CNA C and Laundry Aide D revealed an acknowledgment of the importance of respecting residents' dignity and the inappropriateness of the behavior observed. The facility's policies on resident rights and feeding emphasize the need for a dignified existence and a pleasant dining environment, which were not adhered to in this situation.
Resident Smokes Unsupervised Due to Lapse in Facility's Smoking Policy Enforcement
Penalty
Summary
The facility failed to ensure adequate supervision for a resident who was observed smoking unsupervised in the courtyard during non-smoking times. The resident, who was cognitively intact and had a history of MRSA infection and hypertension, was found smoking without staff supervision, contrary to the facility's smoking policy which required direct supervision for residents assessed as needing it. The resident had been keeping his own cigarettes and lighter, unaware that these items were supposed to be stored at the nurse's station. The facility's smoking policy outlined specific times and staff responsibilities for supervising smoking breaks, but the resident was observed smoking outside of these designated times without supervision. Interviews with staff revealed inconsistencies in the enforcement of the smoking policy, with some staff unaware of the resident's possession of smoking materials and others not ensuring the resident's smoking items were stored securely. The resident had been informed he could leave his room as long as his wounds were covered, which may have contributed to the misunderstanding about smoking supervision. The facility's policy required regular assessments and revisions of the smoking care plan, but it appears there was a lapse in communication and enforcement of these procedures. Staff interviews indicated that while there was a process for assessing and supervising smoking, it was not consistently followed, leading to the resident smoking unsupervised. The facility's failure to adhere to its own smoking policy placed the resident and potentially others at risk of injury or accidents.
Medication Administration Errors Due to Inadequate Pharmaceutical Services
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to medication administration errors. For Resident #34, a Licensed Vocational Nurse (LVN E) administered Furosemide 40 mg despite the resident's blood pressure being below the prescribed parameter of SBP <110. The resident's blood pressure was recorded at 95/84, which should have prompted the nurse to hold the medication. LVN E admitted to not checking the parameters in the electronic record before administering the medication, which could have been avoided by expanding the order details. For Resident #74, LVN E administered Vancomycin without checking the vancomycin trough levels, which are crucial for ensuring the medication is within the therapeutic range. The trough level was available in the electronic record, but LVN E did not review it before administration. The resident inquired about the trough results, and LVN E only checked them after starting the medication administration, revealing a trough level of 2.2, which was below the expected range. The facility's Assistant Director of Nursing (ADON A) mentioned that the physician had ordered random trough levels due to the resident's previous medication refusals. Interviews with LVN E and the corporate Director of Nursing (DON) highlighted that the facility's expectation was for lab results to be reviewed prior to medication administration and for all parameters to be followed. The facility's policies on medication administration and physician orders emphasize the importance of reviewing orders and lab results to prevent medication errors and adverse drug reactions. However, these procedures were not followed, leading to the deficiencies observed.
Failure to Complete PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. This deficiency was identified for one resident who was reviewed for preadmission screenings. The resident, a 68-year-old male, was admitted with diagnoses including cognitive communication deficit, anxiety disorder, and depression disorder. Despite a positive Level I PASRR screening indicating mental illness, the facility did not refer the resident for a PASRR Evaluation at the time of admission. The resident's care plan did not address the positive PASRR Level I for mental illness, and there were no orders for therapy or medication management for depression and anxiety. The facility's administrator, who was covering social worker tasks, admitted to not having received training on the PASRR process. The MDS Coordinator was unaware of the timeline or facility policy for notifying state authorities about positive Level I PASRR residents. Although an email from the local authority confirmed receipt of the PASRR email, the MDS Coordinator did not follow up or document the communication. The resident's PASRR Evaluation was eventually completed, but the documentation was not filed in the resident's medical records at the time of the investigation. The facility's policy requires all PASRR-related forms and communications to be maintained in the resident's medical record, but this was not adhered to. The lack of documentation and follow-up could have resulted in the resident not receiving necessary mental health services, although the evaluation was completed prior to the resident's discharge.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan for a resident within 48 hours of admission, which is necessary to provide effective and person-centered care. The resident, a 68-year-old male, was admitted with diagnoses including cognitive communication deficit, anxiety disorder, and depression disorder. Despite these conditions, the baseline care plan did not address the resident's positive PASRR Level I for mental illness, anxiety disorder, and depression disorder. This oversight was identified during a record review, as the resident had already been discharged and was not available for interview or observation. The facility was operating without a Director of Nursing (DON) at the time, and the responsibility for initiating and completing baseline care plans fell to all facility nurses, including the Administrator (ADM). The ADM acknowledged the expectation for accurate and individualized care plans to prevent a decline in resident abilities. The MDS RN stated she was not responsible for monitoring care plans during the interim period without a DON, and the corporate nurse was visiting the facility daily to address clinical concerns. The facility's policy requires comprehensive care plans to be developed and implemented to meet residents' medical, nursing, and psychosocial needs, but this was not adhered to in the case of the resident in question.
Unsafe Smoking Practices and Supervision Deficiencies
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for four residents who were reviewed for hazards. Specifically, the facility did not ensure that two residents did not keep cigarettes and lighters on themselves, and two other residents were observed picking up cigarette butts from the ground to reuse. These actions placed the residents at risk of being burned. Resident #1, a male with a history of dementia, anxiety disorder, and nicotine dependence, was observed smoking outside unsupervised and keeping cigarettes and a lighter in his pocket. Similarly, Resident #4, diagnosed with chronic obstructive pulmonary disease and mild cognitive impairment, was also seen smoking unsupervised with smoking materials in his possession. Both residents had care plans indicating they should not store smoking materials in their rooms, yet they were able to keep these items on their person. Resident #2, diagnosed with dementia and schizophrenia, and Resident #3, with type 2 diabetes and cognitive communication deficit, were both observed picking up cigarette butts from the ground and storing them in their pockets. Despite having intact cognition scores, these residents engaged in unsafe smoking practices. The facility's policy stated that smoking materials should not be kept in residents' rooms and that residents assessed as unsafe should be supervised, yet these guidelines were not followed, leading to the observed deficiencies.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure that a resident received proper foot care, specifically by not having her toenails trimmed by a podiatrist. The resident, who has severe cognitive impairment and multiple medical conditions including Alzheimer's Disease, was observed with untrimmed and thick, yellow toenails, some of which were curled and potentially causing discomfort. Despite being referred to a podiatrist in April, the resident did not receive the necessary services, and there was no indication in the progress notes that she was referred or received care from a podiatrist. Interviews with staff revealed a lack of clarity and consistency in the responsibility for nail care. A CNA mentioned that she had not seen a podiatrist visit the resident and that she would trim nails if they were long, except for diabetic residents. An LVN expressed discomfort in trimming the resident's thick and fungal toenails and mentioned that the podiatrist was scheduled to visit soon. The DON and Administrator acknowledged the issue, with the Administrator noting a change in podiatry provider and a failure to re-refer the resident in July. The facility's policy on foot care, dated 2003, outlines goals for maintaining skin integrity, preventing infection, and avoiding injury to the feet. However, the policy does not include a procedure for referring residents to outside services, which contributed to the oversight in ensuring the resident received appropriate podiatry care. The lack of a clear referral process and follow-up led to the resident not receiving timely and necessary foot care, potentially placing her at risk of discomfort and further complications.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide necessary nail care for two residents, leading to deficiencies in maintaining personal hygiene. Resident #2, a male with cerebral infarction, vascular dementia, and a left-hand contracture, was observed with long nails on his right hand, with a yellow substance underneath and around them. His care plan indicated that nail care should be performed on bath days and as necessary, with specific instructions for diabetic residents. However, the staff did not notice or address the condition of his nails. Resident #3, a male with encephalopathy and severe cognitive impairment, was observed with long fingernails in the dining room. Interviews with staff revealed that nail care responsibilities were shared between CNAs, nurses, and a podiatrist, with specific protocols for diabetic residents. Despite these protocols, Resident #3's nails were not trimmed, and staff cited difficulty in managing his nail care due to his mood. The facility's policy on nail care emphasized regular and safe performance to prevent infection and injury, but these guidelines were not followed for the residents in question.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene. Specifically, two residents, identified as Resident #10 and Resident #11, did not receive showers as scheduled. Resident #11, a male with chronic respiratory failure, end-stage renal disease, and muscle weakness, required partial/moderate assistance for showering. Despite having a BIMS score indicating intact cognition and no documented refusals, Resident #11 received only 4 out of 12 scheduled showers in April and 4 out of 13 in May. Similarly, Resident #10, a male with paraplegia requiring supervision or touching assistance, received only 2 out of 11 scheduled showers in May and 2 out of 12 in June. Interviews with staff revealed inconsistencies in documentation and communication regarding shower refusals and completions. The ADON explained the shower schedule and the process for documenting refusals, which involved CNAs attempting to persuade residents up to three times before notifying a nurse. However, the ADL sheets for both residents contained blanks and entries indicating that the activity did not occur, without clear documentation of refusals. Staff interviews indicated a lack of clarity and consistency in the documentation process, with some staff assuming that blanks meant showers were not given and others interpreting the code '8' as a refusal or other reasons. The facility's policy on bed baths and showers did not include procedures for documenting showers or refusals, contributing to the lack of proper documentation. The DON stated that documentation was crucial for tracking whether showers were given or refused, but acknowledged the absence of a specific policy on showers. The MDS Coordinator and CNAs confirmed that training on documentation was provided, but discrepancies in understanding and execution were evident, leading to the deficiency in providing scheduled showers to the residents.
Unsafe Installation of Temporary Air Conditioning Unit
Penalty
Summary
The facility failed to maintain a safe environment in the secured unit dining/activity room, where a window air conditioning unit was installed due to a malfunctioning wall unit. The installation involved a loose power cord from the window unit connected to an unsecured extension cord, which was coiled and resting above a doorway. This setup posed a potential hazard to approximately 22 residents present in the room, as the cords were easily accessible and could lead to accidents or injuries. Interviews with staff, including CNAs, LVN, and maintenance personnel, revealed awareness of the potential risks associated with unsecured cords, especially for residents with conditions such as dementia, bipolar disorder, or impulse disorders. These conditions could increase the likelihood of residents interacting with the cords in harmful ways, such as chewing, choking, or using them as weapons. Despite the staff's understanding of these risks, the temporary solution was implemented without adequate safety measures to secure the cords. The facility's administration acknowledged the use of the window unit as a temporary measure due to high temperatures and the malfunctioning wall unit. However, the ADM admitted to not noticing the unsecured extension cord, and the facility's policy emphasized the responsibility of all staff to report and address hazards immediately. The facility's policy on resident rights also highlighted the importance of providing a safe environment, which was not upheld in this instance.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for one resident involved in an incident. CNA A did not follow the facility's policy to report allegations of abuse when she allegedly observed CNA B holding a resident down in a choke hold. This failure to report the incident could place residents at risk of abuse and lack of timely reporting of incidents. The resident involved was an elderly male with Alzheimer's disease and other cognitive impairments. He required substantial assistance with activities of daily living, including toileting. On the day of the incident, CNA A observed CNA B being verbally aggressive and physically abusive towards the resident. Despite being aware of the facility's policy and having recently attended an in-service on abuse and neglect, CNA A did not report the incident due to fear of retaliation. Interviews with other staff members, including the ADON, RN G, and other CNAs, revealed that they had not observed any signs of abuse or changes in the resident's behavior. The Administrator was also unaware of the incident until it was brought to her attention by the surveyor. The facility's policy requires all staff to report any allegations of abuse immediately, but this protocol was not followed in this case.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator. CNA A did not report an incident where CNA B allegedly grabbed a resident by the neck and held him down in a choke hold. CNA A stated she did not intervene or report the incident due to fear of retaliation and physical harm from CNA B. CNA A also mentioned that she had observed CNA B being verbally aggressive with residents and that other staff, including RN G, were aware of CNA B's behavior but did nothing to address it. The resident involved, a male with Alzheimer's disease and other cognitive impairments, required substantial assistance with daily activities. The incident allegedly occurred during CNA A's training period, and despite being aware of the facility's policy on reporting abuse, CNA A chose not to report the incident to the appropriate authorities. CNA A discussed her observations with other staff members, who advised her to report the abuse to an outside entity rather than the facility. Interviews with other staff members, including CNA E and Hospitality Aide F, revealed that they were not aware of any abuse in the Memory Care Unit and denied that CNA A had reported any such incidents to them. The Administrator was also unaware of the alleged abuse until the surveyor's inquiry. The facility's policy on abuse and neglect emphasizes the residents' right to be free from abuse and the importance of immediate reporting, which was not followed in this case.
Failure to Revise Care Plans for Smoking Supervision
Penalty
Summary
The facility failed to review and revise care plans for two residents, leading to a deficiency in ensuring their safety while smoking. Resident #1, a [AGE] year-old female with diagnoses including paralysis, seizures, and stroke, required direct supervision while smoking as per her Safe Smoking Assessment. However, her care plan did not reflect this need. During an observation, Resident #1 was found smoking unsupervised, with evidence of a cigarette burn on her pants. The resident admitted the burn occurred about a month ago, indicating a prolonged period of unsupervised smoking despite the assessment's findings. Similarly, Resident #2, a [AGE] year-old female with diagnoses including diabetes and a history of falls, also required direct supervision while smoking according to her Safe Smoking Assessment. Her care plan, however, did not include this requirement. During an observation, Resident #2 was found smoking without staff supervision and refused to disclose who had lit her cigarette. The Director of Nursing (DON) acknowledged that residents were only allowed to smoke at designated times with staff present but admitted it was challenging to prevent residents from smoking unsupervised. This failure to update and enforce care plans placed both residents at risk of harm.
Failure to Supervise Residents While Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for five residents who required supervision while smoking. Observations revealed that these residents were found smoking without staff supervision, contrary to their care plans and safe smoking assessments. For instance, Resident #1, who required direct supervision while smoking, was observed smoking alone in the designated area, with evidence of a cigarette burn on her pants. Similarly, Resident #2 was found smoking without supervision and refused to disclose who had lit her cigarette. Resident #3 admitted to keeping his own smoking materials in his room and smoking without staff supervision, despite his assessment indicating the need for direct supervision. Resident #4, who had a care plan intervention for supervision while smoking due to non-compliance with the smoking policy, was also observed smoking without staff present. Resident #5, who required direct supervision while smoking, was found smoking alone, and her monthly smoking assessments had not been completed since October 2023. Interviews with the DON and the Administrator confirmed that residents were not permitted to smoke except at designated times with staff supervision, and that smoking materials were to be kept at the nurse's station. However, it was acknowledged that residents often kept their own smoking materials and smoked without supervision. The facility's smoking policy, dated November 1, 2017, mandates that matches, lighters, or other ignition sources are not to be kept in residents' rooms, and that residents classified as unsafe must be directly supervised while smoking. The policy also requires regular safe smoking assessments and inclusion of supervision needs in the residents' care plans. The facility's failure to enforce these policies and ensure proper supervision placed the residents at risk of injury or harm.
Failure to Provide Privacy Curtains
Penalty
Summary
The facility failed to assure full visual privacy for two residents while their privacy curtains were being laundered. Resident #6, a cognitively intact male with a history of bone infection, diabetes, and amputation, and Resident #7, a cognitively intact male with diabetes, legal blindness, and amputation, were both affected. The privacy curtains were removed on April 13, 2024, due to a bed bug treatment and were not replaced when the residents were moved back into their room on April 17, 2024. This left the residents without privacy during personal care activities such as wound care and incontinence care. Observations on April 20, 2024, confirmed the absence of privacy curtains in the room shared by Residents #6 and #7. Interviews with both residents revealed their discomfort and lack of privacy, with Resident #7 expressing particular concern due to his blindness and reliance on staff for privacy. The facility's Administrator acknowledged that the curtains should have been replaced before the residents were moved back into their room but did not know why this had not occurred. There was no policy in place for privacy curtains at the time of the incident.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for four residents, specifically in the trimming of toenails, which could lead to complications such as fungal infections or other podiatric problems. Resident #1, a [AGE] year-old female with severe cognitive decline and high blood pressure, had overgrown toenails, including a thick and blackened left great toenail. Resident #2, a [AGE] year-old female with severe cognitive deficits and difficulty walking, had grossly overgrown, thick, and curved toenails. Resident #3, a [AGE] year-old male with dementia and diabetes, also had overgrown toenails. Resident #4, a [AGE] year-old male with metabolic encephalopathy and seizures, had severely overgrown toenails and could not recall the last time they were trimmed. Interviews with nursing staff revealed inconsistencies in the facility's approach to toenail care. RN A stated that nursing staff could trim all toenails unless they were thick and deformed, in which case a podiatrist would be consulted. However, LVN B indicated that all toenails had to be trimmed by the podiatrist, and the nursing staff did not perform this task. The DON confirmed that nurses should trim toenails unless they were thickened or deformed, in which case the podiatrist, who visited quarterly, would handle it. A review of podiatry visits showed that the four residents had not been seen by the podiatrist and were not scheduled for an upcoming visit. The facility's policy on nail care emphasized regular and safe nail care to prevent abnormal conditions and infections, but this was not adhered to in these cases.
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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