Fort Worth Transitional Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 850 12th Avenue, Fort Worth, Texas 76104
- CMS Provider Number
- 676255
- Inspections on file
- 64
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Fort Worth Transitional Care Center during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments, fully dependent on staff for incontinence care, was left in urine-soaked bedding for at least seven hours due to staff not performing required two-hourly rounds. Staff interviews and observations confirmed that the resident was not checked or changed as per care plan and facility policy, resulting in the resident being found wet through her brief, sheets, and gown.
A resident with significant physical and cognitive impairments, including left-sided weakness and total dependence on staff, experienced a fall when her mattress overlay was not properly secured, allowing both the overlay and the resident to slide off the bed. Staff interviews and documentation confirmed the overlay had been left with an unsecured strap, and required fall risk assessments were not completed as per facility policy.
A resident with a history of falls, moderate cognitive impairment, and multiple medical conditions was left unsupervised for several hours after an unwitnessed fall, resulting in a leg fracture. Staff failed to perform required two-hour rounding, and the resident's call light was not within reach, leading to a delay in assistance and injury.
A resident who was entirely dependent on staff and received all nutrition via a gastric tube did not receive prescribed enteral nutrition when a CNA paused the feeding pump for incontinence care and failed to restart it or notify a nurse. The facility lacked a policy on gastric tube management, and the ADON confirmed that CNAs were not authorized to operate feeding pumps.
A resident with multiple medical conditions did not receive a physician-ordered urinalysis with C&S due to staff's inability to collect a urine specimen and lack of escalation or documentation of the issue. Nursing staff passed the order between shifts without success, and alternative collection methods were not pursued or communicated to the physician. The facility did not meet its policy requirements for timely laboratory services, resulting in the ordered test not being completed.
The facility failed to implement comprehensive care plans for residents, omitting physician orders for weekly weight monitoring and necessary transfer assistance. This led to unmonitored weight fluctuations and a fall incident during a transfer, highlighting significant care planning deficiencies.
A resident with severe cognitive impairment and multiple medical conditions experienced a significant weight loss due to the facility's failure to conduct weekly weight checks as ordered. The resident's care plan required supervision with eating and monitoring for swallowing difficulties, but the facility did not consistently monitor her weight or food intake. The physician and dietician were not informed of the weight loss, preventing timely interventions. The facility's oversight placed the resident at risk of further health complications.
The facility failed to provide accurate respiratory care for two residents. One resident received 3 liters of oxygen instead of the ordered 2 liters, with no documentation or order for the change. Another ventilator-dependent resident was not repositioned every two hours as ordered, potentially affecting secretion management. The DON was unaware of these issues, and the facility lacked a policy on following physician orders and oxygen use.
A facility failed to act on a pharmacist's recommendation for a gradual dose reduction of a resident's medications, Duloxetine and Zolpidem. The resident, with a history of anxiety, depression, and psychotic disorder, continued receiving the medications without adjustments. Interviews revealed a lack of clarity and responsibility among staff regarding follow-up on pharmacy recommendations.
The facility did not follow the posted lunch menu, serving different items than those listed, which led to residents being unaware of what they would be served. The Head of the dietary department cited supplier issues for the substitutions, and the absence of the DM did not affect the service. However, the lack of communication about menu changes left residents uncertain about their meals.
The facility failed to serve lunch at the scheduled time, resulting in delays and resident dissatisfaction. Lunch was supposed to be served between 12:00 PM and 1:00 PM, but service began at 1:05 PM, with the last resident served at 2:00 PM. Residents expressed hunger and frustration due to the delay. The absence of the DM did not affect the service, but the Head of the kitchen acknowledged the delay. The facility's policy requires meals to be served at regular times, which was not followed.
The facility failed to maintain food safety standards in the 3rd floor's satellite kitchen. Drinks were not covered, risking contamination, and steamtable compartments contained debris, compromising food hygiene. Staff were unaware of the requirement to cover drinks, and the cleanliness of steamtables was neglected, violating the facility's meal service policy.
The facility's pest control program was ineffective, leading to a roach infestation in the Third Floor dining room and resident rooms. Despite monthly treatments, residents and staff reported ongoing issues with roaches, causing discomfort and frustration. The Maintenance Director and Administrator relied on external pest control services and staff documentation, but the measures taken were insufficient to resolve the problem.
A resident dependent on staff for transfers was improperly assisted by a CNA, resulting in the resident being lowered to the floor. The incident was not documented or reported to the necessary parties, including the family and physician, as required by the facility's policy. The resident, with a history of mobility issues and other medical conditions, reported a minor skin injury. The facility's failure to document and notify placed the resident at risk.
A resident experienced a fall during a transfer, which was not documented by the responsible LVN. The resident, who had multiple health conditions and was at risk for falls, was lowered to the floor by an aide. The LVN did not report the incident to the DON, physician, or family, leading to incomplete clinical records and potential risk of injury.
A facility failed to maintain an effective infection control program when an RN did not follow Enhanced Barrier Precautions (EBP) for a resident with a gastric tube. Despite clear postings, the RN administered medications without wearing the required gown, only using gloves. The RN admitted to forgetting due to nervousness, and the DON confirmed the necessity of gown and gloves for high-contact activities as per facility policy.
A resident with severe cognitive impairment had bed rails installed without prior assessment or a physician's order. The hospice company installed the bed rails without notifying the facility, and staff failed to report their presence. The necessary evaluation and order were completed only after surveyors raised questions, potentially placing the resident at risk of entrapment or injury.
The facility failed to conduct pre-employment background checks for a CNA before she began working, leading to her working 60 hours without the necessary checks being completed. This oversight was due to miscommunication and a lapse in following the facility's hiring policy, which requires background checks to be completed before a new hire can start work. The failure to adhere to this policy could potentially expose residents to staff with histories of misconduct.
A facility failed to maintain proper protocols for a resident receiving enteral nutrition, including not elevating the head of the bed during feeding and not labeling the nutrition bottle with the date and time it was hung. These actions could risk aspiration and expired nutrition fluid.
A resident with a PICC line did not receive timely dressing changes, going 10 days without a change, due to a lack of physician orders and documentation. The dressing was observed to be dirty, and staff admitted to not checking or changing it as required. The DON was unaware of the issue, and the facility's policy on PICC lines was not provided.
A facility failed to maintain an effective infection control program when a CNA did not use the required PPE while caring for a resident with a urinary catheter, wound, and feeding tube. Despite a posting indicating Enhanced Barrier Precautions, the CNA only wore gloves, contrary to policy requiring a gown and gloves. Interviews confirmed the oversight and the importance of PPE to prevent infection spread.
A resident was discharged from a facility without proper discharge planning, resulting in a lack of necessary medical equipment and home health services. The resident, who had multiple medical conditions and was non-weight bearing, was left at home without a wheelchair or adequate support, leading to a hospital readmission. The facility failed to ensure timely filing of the NOMNC appeal and did not coordinate effectively with DME and home health providers.
Two residents with catheters were found with their catheter bags on the floor and uncovered, compromising hygiene and dignity. One resident expressed concern about the lack of privacy, while the other noted infrequent emptying of the bag. Staff interviews revealed a lack of adherence to proper catheter care practices, and the facility lacked a specific policy on catheter care.
A resident with dementia and a history of wandering was found without a WanderGuard device, despite care plans and orders requiring daily checks and monitoring. The device was found among personal items, and multiple dates showed lapses in monitoring documentation. The facility's policy on elopement prevention was not followed, leading to the deficiency.
The facility failed to maintain accurate clinical records for a resident with dementia, as staff did not document required behavior monitoring on multiple dates. Interviews revealed that it was the responsibility of the nurse on duty to document behaviors, but chart audits found numerous gaps in the records.
The facility failed to ensure a resident's call light was accessible, despite the resident's severe cognitive impairment and physical disabilities. Observations showed the call light was out of reach, and staff interviews confirmed it should have been within reach at all times, as per facility policy.
A CNA observed inappropriate touching between two residents but did not report the incident to the Administrator immediately, delaying the investigation and response. The incident involved a female resident with severe cognitive impairment and a male resident with mild cognitive impairment and quadriplegia. Despite staff training, the incident was not reported until two days later.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was fully dependent on staff for activities of daily living, including incontinence care, was not provided timely assistance. The resident, who had multiple diagnoses such as hemiplegia, seizure disorder, anxiety disorder, depression, bipolar disorder, and cerebral palsy, was found to be soaked with urine through her brief, draw sheet, and bed sheets. The care plan for this resident required staff to check and assist with toileting every two hours, but on the day in question, the resident had not been changed for at least seven hours, with the last incontinence care provided around 4:00 AM and the next care not occurring until after 11:00 AM. Observations and interviews revealed that the resident's room had a strong smell of urine, and the resident herself reported being wet and needing to be changed. Staff interviews confirmed that the resident was fully incontinent and dependent on staff for care, and that it was not normal for her to be found in such a condition. The CNA assigned to the resident admitted to not having checked on her yet during the shift, citing difficulties in performing two-hourly rounds due to workload and assignment changes. The RN and ADON both stated that staff were expected to check on residents at least every two hours, and acknowledged that the resident should have been checked and changed more frequently. Facility policy required perineal care to be provided during routine baths and as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. Despite this, the resident was left in urine-soaked bedding for an extended period, which was confirmed by multiple staff members and direct observation. No skin issues were noted at the time, but staff recognized that such lapses in care placed the resident at risk for adverse outcomes.
Failure to Secure Mattress Overlay Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was provided with an environment free from accident hazards, specifically by not properly securing the resident's mattress overlay. The resident, who had a history of stroke with left-sided weakness, dysphasia, aphasia, and required a tracheostomy, was totally dependent on staff for all activities of daily living and was assessed as a high fall risk. Despite care plan interventions requiring safe and proper positioning in bed on her air mattress, the mattress overlay was not properly secured, as one of the straps was left unfastened. This oversight resulted in the resident sliding off the bed along with the unsecured mattress overlay, as captured in video footage provided by the family. The incident occurred while the resident was lying in bed and subsequently fell headfirst onto a fall mat beside the bed. Nursing documentation confirmed the resident was found on the floor with the overlay, and no immediate injuries were observed. The family was notified and requested hospital evaluation, where the resident was diagnosed with a urinary tract infection and returned to the facility the same day. Interviews with staff revealed that the overlay had previously been found unsecured and that it was the responsibility of nurses and CNAs to ensure overlays were properly attached. The DON acknowledged that the required fall risk assessments were not completed as scheduled or after the fall event. The facility's policy required fall risk assessments on admission, quarterly, and after any fall, but these were not conducted as required for this resident.
Failure to Provide Adequate Supervision and Accident Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and assistance devices to prevent accidents for a resident with a history of repeated falls, moderate cognitive impairment, and multiple medical diagnoses including liver failure and dementia. The resident required staff assistance with activities of daily living and used a walker for transfers. The care plan identified the resident as being at risk for falls and included interventions such as keeping the bed in the lowest position and ensuring the call light was within reach. Despite these interventions, the resident experienced an unwitnessed fall during the early morning hours, which was not discovered for approximately three hours. On the night of the incident, the resident attempted to transfer from her bed to her chair using her walker and fell at approximately 3:20 AM. The resident's door was closed at her request, making it difficult for staff to hear her calls for help. The resident was not found until 6:20 AM by a nurse making morning rounds. During this time, the resident was heard calling for help on video footage, but staff did not respond. The last documented check by a CNA was at 2:30 AM, and the CNA did not check on the resident again during the remainder of the shift, citing a desire not to wake the resident. The facility's expectation was for staff to round on residents at least every two hours, but this was not followed. As a result of the fall, the resident sustained a fracture to her lower leg and required non-weight bearing status for four weeks. The incident was unwitnessed, and the resident was left on the floor for an extended period before being discovered. Staff interviews confirmed that rounding protocols were not adhered to, and the resident's call light was not within reach at the time of the fall. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure to ensure adequate supervision and accident prevention measures for a resident at high risk for falls.
Failure to Ensure Proper Management of Enteral Feeding Pump
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) paused a resident's enteral feeding pump to provide incontinence care and failed to restart the pump or notify a nurse to do so after the care was completed. The resident, a female with a history of stroke, inability to swallow requiring a gastric tube, and a tracheostomy, was entirely dependent on staff for activities of daily living and received all nutrition via her gastric tube as ordered by her physician. The physician's order specified a continuous feeding regimen using a stationary pump. During observation, the CNA paused the feeding pump before providing care and left the pump paused upon exiting the room, proceeding to round on other residents. The assistant director of nursing (ADON) confirmed that CNAs were not permitted to start, stop, or pause feeding pumps, as the formula was considered a medication. The facility did not have a policy addressing gastric tube feedings or management at the time of the incident.
Failure to Obtain Ordered Laboratory Services for a Resident
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered for a resident who had multiple complex medical conditions, including a history of urinary tract infection, cognitive impairment, and pressure ulcers. Despite physician orders for a urinalysis with culture and sensitivity (C&S) on two separate occasions, there was no evidence in the clinical record that a urine specimen was collected or that lab results were obtained for either order. Nursing staff documented difficulty in collecting a urine sample due to the resident's incontinence and fluctuating ability to cooperate, but did not escalate the issue or document all attempts as required. Interviews with nursing staff and facility leadership revealed that the order for urinalysis was passed between shifts without successful collection, and alternative methods such as straight catheterization were not pursued. The DON and ADON acknowledged that the nurses should have contacted the physician for further instructions or to obtain an order for straight catheterization, but this was not done. The nurses also failed to consistently document their attempts to collect the specimen or to communicate the ongoing issue during daily clinical meetings as expected by facility policy. The resident was ultimately transferred to the hospital by family due to concerns of increased confusion, and hospital records indicated that no urinary infection was found. The facility's policy required timely provision or procurement of laboratory services when ordered, but this was not met in the resident's case, as the ordered urinalysis was not completed and the process for addressing collection difficulties was not followed.
Deficiencies in Care Planning and Monitoring
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, which resulted in deficiencies in addressing specific medical orders and needs. For four residents, the care plans did not include physician orders for weekly weight monitoring, despite the presence of conditions such as feeding tube requirements and cognitive impairments. This oversight was evident in the records of residents who experienced weight fluctuations, indicating a lack of adherence to prescribed monitoring protocols. Additionally, the facility did not create a care plan for a resident requiring a mechanical lift for transfers, which led to an incident where the resident fell during a transfer attempt. The resident, who had a history of mobility issues and was dependent on staff for transfers, was not adequately care planned for the use of a mechanical lift, resulting in a fall and minor injury. The resident's care plan lacked specific interventions for safe transfer assistance, which contributed to the incident. The Director of Nursing acknowledged the failure to weigh residents as ordered and indicated a need for staff education on following physician orders. The lack of comprehensive care planning placed residents at risk for potential weight loss, nutritional decline, and injury during transfers, highlighting significant gaps in the facility's care planning processes.
Failure to Monitor Resident's Weight Leads to Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in a significant weight loss of 7.75%. The resident, an elderly female with severe cognitive impairment and multiple medical conditions including anemia, high blood pressure, end-stage renal disease, dysphagia, and non-Alzheimer's dementia, was not weighed weekly as per physician orders. The missed weight checks occurred over several weeks, and the facility did not alert the physician or dietician about the resident's weight loss, which could have prompted timely interventions. The resident's care plan indicated a need for supervision with eating and monitoring for signs of swallowing difficulties. Despite these requirements, the facility did not consistently monitor the resident's weight or food intake, leading to a lack of awareness of her declining nutritional status. Interviews with staff revealed that the responsibility for weighing residents was not clearly executed, with aides and nurses failing to ensure the resident was weighed according to schedule. This oversight contributed to the resident's unmonitored weight loss. The physician and dietician were not informed of the resident's weight loss, which hindered their ability to address the issue promptly. The dietician noted that the resident had been on a puree diet, which she disliked, and had recently transitioned to a mechanical soft diet. However, the lack of consistent weight monitoring meant that the dietician was unaware of the resident's weight decline until it was observed during a survey. The facility's failure to follow its weight monitoring policy placed the resident at risk of further weight loss and associated health complications.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide accurate respiratory care for two residents requiring oxygen therapy. For one resident, the facility did not have accurate physician orders for oxygen use. The resident was observed receiving 3 liters of oxygen via nasal cannula, despite the physician's order for 2 liters. The Licensed Vocational Nurse (LVN) confirmed the discrepancy and noted that there was no documentation or order for the increased oxygen level. The Director of Nursing (DON) was unaware of the change and emphasized the importance of following physician orders, highlighting a lack of communication and documentation regarding the resident's oxygen needs. Another resident, who was ventilator-dependent, was not repositioned every two hours as ordered by the physician. Observations revealed that the resident remained in the same position for extended periods, which could hinder the expectoration of secretions. An LVN expressed difficulty in repositioning the resident due to the need to disconnect the ventilator, and admitted to not performing passive range of motion exercises due to a lack of training. The DON acknowledged that repositioning should not be avoided due to difficulty and was unaware of the specific repositioning order. These deficiencies in respiratory care could place residents at risk for inadequate oxygen delivery and potential complications. The facility lacked a policy on following physician orders and oxygen use, which contributed to the oversight in care for these residents.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to act upon drug regimen irregularities reported by the Pharmacist Consultant for a resident. The Pharmacist Consultant recommended a gradual dose reduction for the resident's Duloxetine and Zolpidem, but this recommendation was not communicated to the resident's primary care physician. This oversight could place residents at risk for adverse consequences and a decline in their condition. The resident in question was a female with a history of anxiety disorder, depression, and psychotic disorder, who was receiving antipsychotics, antidepressants, and hypnotics. Despite the Pharmacist Consultant's recommendation for a dose reduction, there was no documentation of an attempt or a clinical contraindication by the physician. The resident continued to receive the medications as ordered without any adjustments. Interviews with facility staff revealed a lack of clarity and responsibility regarding the follow-up on pharmacy recommendations. The Assistant Director of Nursing (ADON) was unsure of the process and frequency for considering gradual dose reductions (GDRs), and the Director of Nursing (DON) acknowledged the oversight and the need for improvement. The facility's policy required drug regimen reviews to be conducted by the pharmacist, with recommendations communicated to the attending physician, but this process was not effectively implemented in this case.
Failure to Follow Posted Menu
Penalty
Summary
The facility failed to adhere to the posted lunch menu on January 28, 2025, which was supposed to include roast beef, dill potatoes, red cabbage, wheat bread, margarine, ice cream, coffee or tea, and a garnish parsley sprig. Instead, the meal served consisted of beef tips, rosemary potatoes, green cabbage, a roll, and pears. This discrepancy was observed during the lunch service and was confirmed through interviews with both residents and staff. A resident expressed that the menu was not usually posted or followed, leading to uncertainty about what meals would be served. The Head of the dietary department acknowledged that substitutions were made due to the unavailability of certain items from the supplier, and the absence of the Dietary Manager (DM) on that day did not disrupt the lunch service. However, the Head admitted that the residents were not informed of the menu changes until they received their meals, which did not match the posted menu. The DM later confirmed that the menu should be posted daily and any changes should be communicated to the residents to avoid misleading them. The failure to follow the menu could affect all residents by not informing them of what they would be served, potentially impacting their meal satisfaction and dietary preferences.
Delayed Meal Service Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to ensure that residents received meals at regular times comparable to normal mealtimes in the community or in accordance with resident needs and preferences. On the day in question, lunch was scheduled to be served between 12:00 PM and 1:00 PM, but the service was delayed. Observations revealed that the dietary staff began taking food temperatures at 12:40 PM, and one of the food items, rosemary potatoes, was not at the correct temperature and had to be reheated. As a result, the lunch service did not begin until 1:05 PM, and the last resident was served at 2:00 PM. Interviews with residents indicated dissatisfaction with the meal service timing, with one resident expressing that lunch was often served late and another stating they were starving due to the delay. The Head of the kitchen acknowledged the delay and mentioned that the absence of the Dietary Manager (DM) did not interrupt the lunch service, although the meal was not served on time. The DM, upon return, expressed surprise at the delay and noted that such delays could impact residents' medication schedules, therapy, and conditions like diabetes. The facility's policy requires meals to be served at regular times, with at least a four-hour interval between meals, which was not adhered to in this instance.
Food Safety Deficiencies in Satellite Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the 3rd floor's satellite kitchen, specifically in the areas of drink coverage and steamtable cleanliness. Observations revealed that drinks leaving the kitchen were not covered, which could lead to contamination. Interviews with CNAs indicated they were unaware of the requirement to cover drinks, and the Head of the kitchen acknowledged that lids were supposed to be provided but was unsure if they were available on the day in question. The Dietary Manager (DM) confirmed that drinks should be covered to prevent cross-contamination. Additionally, the facility did not ensure the cleanliness of the steamtable compartments before placing food in them. Observations showed cloudy water with debris in the steamtable compartments, which were used to serve various food items. The Head of the kitchen admitted to not checking the water before placing food containers on the line and acknowledged that the water should have been clean to prevent contamination. The DM stated that the steamtables should be drained and cleaned every night to maintain hygiene and prevent debris from contaminating the food. The facility's policy on meal service, which requires the cleaning and sanitizing of food-contact surfaces and equipment, was not followed. This policy mandates that all multi-use utensils and food-contact surfaces be cleaned and sanitized prior to each use, and at scheduled intervals during food preparation. The failure to adhere to these procedures could potentially expose residents to food-borne illnesses and contamination, as the facility did not maintain the required standards for food safety and hygiene.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the Third Floor dining room and resident rooms. Observations and interviews revealed that roaches were seen along the baseboards in the dining room while residents were present, and residents reported seeing roaches in their rooms and personal belongings. Despite monthly pest control treatments documented in the facility's records, residents expressed that the measures taken were ineffective, and they felt uncomfortable and frustrated with the ongoing pest issue. Interviews with staff, including a CNA and the Maintenance Director, confirmed the presence of roaches in resident rooms and common areas. The CNA reported the issue in the pest control logbook, while the Maintenance Director acknowledged seeing roaches but stated that pest control was the responsibility of an external company. The Administrator, who had not personally observed roaches, relied on the pest control company’s reports and staff documentation to address pest issues. The facility's pest control policy outlined regular service schedules and communication protocols, but the ongoing presence of roaches indicated a failure in effectively implementing these measures.
Failure to Ensure Adequate Supervision and Assistance Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident, identified as Resident #194, who was dependent on two or more staff for transfers. On a specific date, a CNA failed to safely transfer the resident, resulting in the resident being lowered to the floor. This incident was not documented or reported to the necessary parties, including the family, physician, and facility leadership, as required by the facility's Fall Prevention Program policy. Resident #194, a cognitively intact male with a BIMS score of 15, had functional limitations and was dependent on staff for transfers. His medical history included conditions such as abnormalities of gait and mobility, muscle wasting, lack of coordination, Type 1 Diabetes, stroke, and renal insufficiency. The resident's care plan indicated a moderate risk for falls, but it did not specify the level of assistance required for transfers. After the incident, the resident reported a skin injury to his elbow, which was observed to be healing, and he was subsequently transferred using a mechanical lift with two staff members. Interviews with facility staff revealed that the incident was not initially considered a fall by the LVN on duty, who did not document or report it. The DON later confirmed that the incident should have been reported and documented according to protocol. The facility's policy defines a fall as an event where an individual unintentionally comes to rest on the ground, and a near miss is also considered a fall if the resident would have fallen without intervention. The lack of documentation and notification placed the resident at risk of injury and his family at risk of not being informed about his health status.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who experienced a fall. The incident involved a male resident who was dependent on staff for transfers and had multiple health conditions, including Type 1 Diabetes, stroke, and renal insufficiency. The resident was at moderate risk for falls due to deconditioning and gait/balance problems. Despite these risks, the facility did not document a fall that occurred during a transfer. The incident was first brought to attention when the resident's family member inquired about a fall the resident had mentioned. Upon investigation, it was revealed that the resident was lowered to the floor by an aide during a transfer to bed. LVN B, who was responsible for the resident during the shift, did not document the fall or report it to the necessary parties, including the DON, physician, or family. LVN B did not consider the lowering to the ground as a fall and therefore did not follow the facility's protocol for documentation and notification. The lack of documentation and communication placed the resident at risk of injury, as the staff was not properly informed of the resident's change in status. The DON confirmed that LVN B did not follow the facility's protocol, which required documentation and notification of any changes in a resident's condition. This failure to document and communicate the fall could potentially affect other residents who require assistance with transfers, as it may lead to inaccurate or incomplete clinical records.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a registered nurse (RN) who did not adhere to the required Enhanced Barrier Precautions (EBP) for a resident. The resident was on EBP due to having a gastric tube, which necessitated the use of a gown and gloves during direct care activities to prevent the transmission of infections. Despite the clear posting outside the resident's room indicating the need for such precautions, the RN administered medications via the resident's gastric tube and a subcutaneous injection while only wearing gloves, omitting the required gown. During an interview, the RN admitted to forgetting to wear the necessary personal protective equipment (PPE) due to nervousness caused by the presence of a surveyor. The Director of Nursing (DON) confirmed that all staff are required to wear a gown and gloves when providing direct care to residents on EBP, especially when performing high-contact activities such as medication administration via a gastric tube. The facility's policy on EBP, dated April 2024, outlines the necessity of these precautions to reduce the transmission of multi-drug-resistant organisms.
Failure to Follow Bed Rail Procedures
Penalty
Summary
The facility failed to follow proper procedures before installing bed rails for a resident, leading to a deficiency. The resident, who was admitted to the facility with severe cognitive impairment and other medical conditions, had bed rails installed without prior assessment or a physician's order. The resident's admission records and care plan did not initially reflect the use of bed rails, and the necessary evaluation and order were only completed after surveyors inquired about the situation. The Director of Nursing (DON) acknowledged that the bed rails were installed by the hospice company without notifying the facility, and the staff failed to notice and report the presence of the bed rails. This oversight resulted in the absence of an evaluation and order to ensure the appropriateness of the bed rails for the resident, potentially placing the resident at risk of entrapment or injury. The DON admitted that the nursing department was responsible for ensuring the proper procedures were followed, including obtaining an order and conducting an evaluation before the installation of bed rails.
Failure to Conduct Pre-Employment Background Checks for CNA
Penalty
Summary
The facility failed to conduct a pre-employment nurse aide registry check to determine if CNA A met competency evaluation requirements before starting work. CNA A was hired on 11/18/24, but the necessary background checks, including the Texas Criminal History Registry, EMR, and NAR checks, were not completed until after she began working. The HRC, responsible for completing these checks, acknowledged that CNA A was placed on the schedule due to a miscommunication and oversight, leading to her working 60 hours before the checks were finalized. The Interim Administrator and DON confirmed that CNA A started working with residents without the necessary background checks being completed. The facility's hiring policy requires background checks to be completed before a new hire can officially begin work, but this was not adhered to in CNA A's case. The failure to complete these checks before CNA A started working could potentially expose residents to staff with histories of misconduct, increasing the risk of abuse or neglect.
Failure to Maintain Proper Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications associated with tube feeding. Specifically, the facility did not maintain the required elevation of the resident's head while the tube feeding was infusing. Observations revealed that the resident was lying flat on his back, contrary to the care plan's directive to keep the head of the bed elevated to 45 degrees during feeding. This oversight was confirmed through interviews with facility staff, who acknowledged the necessity of maintaining head elevation to prevent aspiration. Additionally, the facility did not adhere to proper protocols for labeling the resident's liquid nutrition. The bottle of liquid nutrition was observed without a date or time indicating when it was hung, which is essential for ensuring the nutrition fluid is not expired. Interviews with the LVN and DON confirmed that the bottle should be labeled with the time, date, rate, and name, and that it is only good for 24 hours. These lapses in care could place residents at risk of aspiration and receiving expired nutrition fluid.
Failure in PICC Line Management and Documentation
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of intravenous (IV) fluids for a resident, specifically in the management of a peripherally inserted central catheter (PICC) line. The resident, a male with a history of acute osteomyelitis and methicillin-resistant Staphylococcus aureus (MRSA) infection, did not have his PICC line dressing changed for 10 days. There were no physician orders for PICC line dressing changes and flushes, and the facility's treatment administration records lacked documentation of any dressing changes. The resident's care plan addressed IV medication but did not include interventions for PICC line dressing changes. Observations revealed that the PICC line dressing was intact but dirty, and the resident confirmed it had not been changed since being applied at the hospital. A Licensed Vocational Nurse (LVN) admitted to not checking the dressing date and acknowledged the dressing should have been changed. The Director of Nursing (DON) expected staff to change PICC dressings every seven days but was unaware of the oversight. The facility's policy on PICC lines was not provided upon request, and there was no evidence of staff training on PICC line management.
Inadequate PPE Use During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA D, who did not adhere to the required Enhanced Barrier Precautions while providing care to a resident. The resident, a male with cerebral palsy, seizures, cognitive communication deficit, and difficulty swallowing, was admitted with a urinary catheter, a wound to his hip, and a feeding tube. Despite the posting on the resident's door indicating the need for a gown and gloves, CNA D only wore gloves during incontinence care, which was not in compliance with the facility's policy. Interviews with CNA E and the ADON confirmed the oversight, with CNA E admitting to not reading the posting and acknowledging the importance of Enhanced Barrier Precautions in preventing infection spread. The ADON and DON reiterated the requirement for staff to wear appropriate PPE, including gowns and gloves, for residents on Enhanced Barrier Precautions. The facility's policy, dated earlier in the year, clearly outlined the need for such precautions for residents with wounds or indwelling medical devices, regardless of known infection status.
Failure in Discharge Planning and Coordination
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for a safe and orderly discharge of a resident. The resident, who was cognitively intact with a BIMS score of 13, had multiple medical conditions including lower extremity weakness, hypertension, diabetes, and a recent fracture. Despite these conditions, the facility did not ensure that the resident's NOMNC appeal was filed in time, resulting in the resident being discharged without the necessary support and equipment. The social worker and MDS nurse did not follow up adequately with the DME provider to ensure the delivery of the resident's wheelchair, nor did they provide the correct address to the home health care provider. As a result, the resident was discharged without essential medical equipment and home health services. The resident was left at home without a wheelchair, unable to move or attend to personal needs, and was eventually taken to the hospital due to the unsafe discharge. Interviews with various staff members and family revealed a lack of communication and coordination in the discharge planning process. The facility's discharge planning policy was not effectively implemented, leading to the resident being discharged without the necessary support systems in place. This oversight placed the resident at risk of health decline and necessitated readmission to a healthcare facility.
Deficiency in Catheter Care and Resident Dignity
Penalty
Summary
The facility failed to provide appropriate care for two residents with catheters, leading to deficiencies in maintaining catheter hygiene and privacy. Resident #1, a male with moderate cognitive impairment and multiple health conditions, including renal insufficiency and obstructive uropathy, was observed with his catheter bag on the floor without a privacy cover. This was noted during an observation when the resident was in his room, and the catheter bag was not handled by the CNA who delivered his lunch tray. The resident expressed a desire for his catheter bag to be covered, especially after a recent urinary tract infection. Similarly, Resident #2, a female with severe cognitive impairment and a suprapubic catheter due to neurogenic bladder, was found with her catheter bag full, on the floor, and uncovered. The resident expressed a need for more frequent emptying of the bag, as it sometimes felt like it was backing up. Interviews with the CNAs revealed a lack of attention to ensuring the catheter bags were covered and off the floor, which is crucial for maintaining resident dignity and preventing infection. The facility's staff, including CNAs and LVN, acknowledged the importance of keeping catheter bags covered and off the floor to prevent infection and maintain resident dignity. However, there was a lack of adherence to these practices, as evidenced by the observations and interviews. The Director of Nursing confirmed the expectation for all catheter bags to be covered and properly positioned, but the facility did not have a specific policy regarding indwelling Foley catheter care.
Failure to Ensure Resident Wore WanderGuard Device
Penalty
Summary
The facility failed to ensure that Resident #1, who had dementia and a history of wandering, was wearing a WanderGuard device as care planned to prevent elopement. Resident #1, a [AGE] year-old female with moderate cognitive impairment and a history of wandering, was observed without the WanderGuard device on her ankle. The device was found among personal items on the resident's bedside table, with signs of tampering and disrepair. Despite the care plan and orders specifying the need for daily checks and monitoring of the WanderGuard, there were multiple dates in April 2024 where no entries were made in the Monitoring Administration Record (MAR) for the day shift, indicating lapses in monitoring and documentation by the staff. During an interview, the Licensed Vocational Nurse (LVN) on duty claimed to have checked the WanderGuard that morning, but upon inspection, the device was not on Resident #1. The LVN then educated the resident about the necessity of wearing the WanderGuard and initiated one-on-one monitoring to prevent exit-seeking behaviors. The Director of Nursing (DON) confirmed that residents with a BIMS score below 13 required a WanderGuard and that the nursing staff were responsible for ensuring the device was intact and functioning. The DON acknowledged that failure to complete the monitoring placed residents at risk of exiting the building and potential harm. The Administrator also confirmed that all residents with a BIMS score below 13 should have WanderGuards and that the facility had additional security measures, such as secured elevators, to prevent elopement. However, the Administrator was unaware that Resident #1 did not have the WanderGuard on and acknowledged the risk of residents exiting the building unattended. The facility's policy on Elopements and Wandering Residents emphasized the need for adequate supervision and systematic monitoring to prevent accidents, which was not adhered to in this case, leading to the deficiency.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for one resident reviewed for clinical records. Specifically, the facility did not ensure that staff accurately documented on the resident's Skilled Administration Record that she was being monitored for her behaviors. The resident, a female with dementia and severe cognitive impairment, had a care plan that required monitoring for inappropriate behavior towards staff and other residents. However, multiple dates in April 2024 had no entries documenting this monitoring, indicating a lapse in record-keeping by the staff on duty during those shifts. Interviews with staff, including an LVN and the Interim DON, revealed that it was the responsibility of the nurse on duty to document any behaviors during their shift on the resident's MAR/TAR. The Interim DON acknowledged finding numerous gaps in the residents' MARs/TARs during chart audits, emphasizing that this documentation is a legal requirement to ensure proper monitoring. The facility's policy mandates that licensed staff document all assessments, observations, and services provided in the resident's medical record at the time of service or no later than the shift in which the care occurred. The failure to adhere to this policy resulted in incomplete and inaccurate clinical records for the resident in question.
Failure to Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a critical aspect of accommodating resident needs and preferences. Resident #5, a male with severe cognitive impairment and multiple physical disabilities, was observed on two separate occasions with his call light out of reach, underneath his roommate's bed. This resident is dependent on staff for most activities of daily living and is at moderate risk for falls due to his impaired mobility and functional quadriplegia. Despite the care plan specifying that the call light should be within reach, staff did not adhere to this requirement, potentially compromising the resident's ability to call for assistance when needed. During an interview, the Interim DON confirmed that it is the responsibility of CNAs and nurses to ensure that call lights are within reach of residents at all times. The facility's policy on call light accessibility also mandates that call lights should be within reach and secured as needed. However, observations and interviews revealed that this policy was not followed, as evidenced by the call light being out of reach for Resident #5. This failure could lead to significant risks for the resident, including falls and unmet needs for assistance.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the Administrator for two residents reviewed for abuse. Specifically, a CNA observed inappropriate touching between two residents but did not report the incident to the Administrator immediately. The incident occurred on a Saturday, but the Administrator was not informed until the following Monday, delaying the investigation and response to the alleged abuse. Resident #3, a female with severe cognitive impairment and a history of physical behaviors towards others, was observed touching Resident #4, a male with mild cognitive impairment and quadriplegia. Resident #4 was seen grabbing Resident #3's breast and later placing her hand on his crotch area. The CNA who witnessed the incident reported it to a nurse on duty, but the nurse did not escalate the report to the Administrator immediately. The delay in reporting was confirmed through interviews with the CNA, the nurse, and the Administrator. The Administrator emphasized that all staff are trained to report any allegations of abuse immediately to ensure timely investigation and intervention. Despite this training, the incident was not reported until two days later, highlighting a failure in the facility's abuse reporting protocol.
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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