Green Valley Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 6850 Rufe Snow Dr, Fort Worth, Texas 76148
- CMS Provider Number
- 676161
- Inspections on file
- 52
- Latest survey
- September 5, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at Green Valley Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments, who required a mechanical lift and two-person assistance for transfers per physician orders, was manually transferred by a CNA with help from a family member. This improper transfer resulted in a shoulder dislocation and humeral neck fracture, as the required equipment and staffing were not used in accordance with the care plan and facility policy.
Multiple resident rooms and air conditioning units were found with significant dirt, dust, and stains, including unclean vents, stained bathroom fixtures, and dirty mini fridges. Housekeeping and maintenance staff acknowledged that cleaning had not been thorough, despite facility policy requiring daily cleaning to ensure a sanitary environment.
Surveyors found that the facility failed to maintain proper food storage, preparation, and equipment sanitation standards. The kitchen's ice machine and scoop holder had visible stains, cooking equipment was dirty, and food items were not properly labeled or dated. Additionally, a tea dispenser was left uncovered, and several food storage policies were not followed, as confirmed by staff interviews.
Staff failed to maintain the confidentiality of resident medical information by leaving documents and medication packaging containing personal health details unattended and visible on carts in hallways and at the nurses' station. These items included names, diagnoses, medication details, and other sensitive information, and were left without supervision, making them accessible to unauthorized individuals.
Surveyors found that several residents requiring oxygen therapy did not receive care consistent with professional standards, including improper storage of nasal cannulas, an empty humidifier bottle, and missing "Oxygen In Use" signage. Staff interviews confirmed these lapses, and facility policy required these safety measures to be in place.
Staff failed to follow infection control protocols, including proper hand hygiene, glove changes, and use of gowns during incontinent care, medication administration via feeding tube, and wound care for several residents with significant medical needs and on enhanced barrier precautions. These lapses were observed among a CNA, an LVN, and a wound care nurse, despite facility policies requiring these practices.
Two residents identified as high fall risk were provided with fall prevention equipment—a scoop mattress and bolster pads—without the required physician orders. Both residents were totally dependent for ADLs and had diagnoses including dementia and unsteadiness. The absence of physician orders for this equipment was confirmed by an LVN and the DON during interviews and record reviews.
Two residents with severe cognitive impairment and high dependence on staff were found without accessible call lights in their rooms, as required by their care plans and facility policy. Staff interviews confirmed that call lights are essential for requesting assistance, but in both cases, staff failed to ensure the devices were within reach after providing care or medication.
A CNA failed to follow proper perineal care technique by wiping from back to front during incontinent care for a resident with a history of UTI and severe cognitive impairment. This action was inconsistent with the resident's care plan and facility policy, which require front-to-back cleaning to prevent infection.
Two residents with g-tubes did not have tube placement or gastric residual checked before medications were administered by an LVN, despite physician orders and care plans requiring these steps. The LVN acknowledged forgetting to perform the checks, and facility leadership confirmed that these procedures are expected as part of enteral feeding management.
A resident with a history of peripheral artery disease (PAD) was not provided with adequate care and monitoring by the facility. Despite known risks, the facility failed to conduct regular skin assessments and did not implement a comprehensive care plan addressing the resident's PAD. This oversight led to the resident being transferred to the hospital with significant skin issues, including gangrenous toes, highlighting a lack of communication and documentation among staff.
A resident with a history of metabolic encephalopathy, acute kidney failure, E. coli infection, and type 2 diabetes developed a deep tissue pressure injury due to the facility's failure to perform consistent skin assessments and implement necessary interventions. Despite being at risk for pressure ulcers, the facility did not adequately monitor or document the resident's skin condition, leading to a diagnosis of a deep tissue pressure injury and ischemic eschar upon hospital transfer. Staff interviews revealed a lack of communication and adherence to the facility's pressure ulcer prevention policies.
A facility failed to create comprehensive care plans for a resident, neglecting to address risks of altered skin integrity and peripheral artery disease (PAD). The resident, with multiple diagnoses and requiring substantial assistance, lacked a care plan focusing on impaired skin integrity or pressure injury prevention. Staff interviews revealed confusion over care plan responsibilities, and there were no orders for pressure-relieving devices for the resident's heels. This oversight could negatively impact the resident's quality of life and care.
The facility failed to maintain respiratory equipment according to professional standards for three residents requiring respiratory therapy. Observations showed undated nasal cannulas and improperly stored nebulizer masks, potentially leading to respiratory infections. Residents with dementia and respiratory conditions were affected, and staff interviews revealed inconsistencies in following protocols for equipment maintenance.
Two residents with feeding tubes were found with unlabeled enteral feeding formula and water bags, and improperly stored piston syringes, posing risks of contamination and infection. Despite care plans requiring specific feeding interventions, nursing staff failed to adhere to protocols due to oversight and workload.
A resident with paraplegia and stage 4 pressure ulcers exhibited altered mental status and hallucinations for over 22 hours without timely notification to the physician or responsible party. Despite staff observations of the resident's deteriorating condition, including hallucinations and sweating, there was a lack of documentation and communication, leading to a diagnosis of severe sepsis at a hospital.
A resident with complex medical conditions experienced a decline in well-being due to the facility's failure to monitor and report changes in bowel movements and mental status. Despite being at risk for constipation, the resident did not receive prescribed PRN medication, and significant symptoms were not communicated to the provider, resulting in hospitalization for severe sepsis and fecal impaction.
A resident with complex medical conditions was not promptly notified to the physician about STAT lab results, leading to hospitalization for severe sepsis and chronic constipation. Despite being at risk for constipation due to medications, the facility failed to administer MiraLax or document interventions. Staff interviews revealed communication lapses, and the physician was not informed of the lab results timely, placing the resident at high risk for complications.
Failure to Follow Transfer Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who had multiple medical conditions including hemiplegia, hemiparesis, muscle weakness, and was dependent on staff for all activities of daily living, was transferred without the required mechanical lift and two-person assistance. The resident's care plan and physician orders specified that transfers must be performed using a mechanical lift with two staff members due to her inability to bear weight and significant physical debility. Despite these clear directives, a CNA manually transferred the resident with the assistance of a family member, rather than using the mechanical lift as ordered. During the manual transfer, the CNA bear-hugged the resident and, while holding her up, a popping sound was heard from the resident's right arm. The resident immediately expressed severe pain, and subsequent assessment and hospital evaluation revealed an anterior shoulder dislocation and a right humeral neck fracture. Interviews with staff and the resident's representative confirmed that the transfer was performed by a single CNA without the mechanical lift, and that the family had previously requested that the lift not be used. The CNA admitted to having transferred the resident manually on prior occasions, despite knowing the care plan and physician orders required the use of a mechanical lift with two staff. Facility policy required strict adherence to physician orders for transfers, including the use of mechanical lifts for non-weight-bearing residents, and mandated that staff not deviate from these orders even if requested by residents or their families. The incident was reported by staff, and it was acknowledged by the DON and other staff members that the CNA's actions were not in compliance with established protocols and orders. The failure to follow the prescribed transfer method directly resulted in a significant injury to the resident.
Failure to Maintain Clean and Sanitary Resident Rooms and Air Conditioning Units
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in 13 out of 16 rooms on the 100 hall, as well as the air conditioning unit on the same hall. Observations revealed that multiple resident rooms had significant cleanliness issues, including thick black and brown dirt along and between air conditioning vents, thick white substances between vents, and thick dust on air filters. Additional findings included brownish stains on bathroom sink faucets, brown stains along the edges and corners of bathroom floors and door frames, stained bed frames, and dirty mini fridges. Some rooms also had thick dirt in the corners of the floors and stained picture frames and toilets. Interviews with housekeeping staff and supervisors confirmed that staff were responsible for cleaning all areas of the resident rooms, including bathrooms, air conditioning units, and mini fridges. However, the staff acknowledged the observed deficiencies and stated that cleaning had not been thorough. The maintenance director confirmed responsibility for cleaning the inside of air conditioning units and air filters, stating that these were supposed to be cleaned monthly, but the observed conditions indicated this was not being done adequately. The facility's policy on resident room cleaning emphasized the importance of daily cleaning to maintain a sanitary environment and prevent odors. Despite this policy, the observed conditions and staff interviews demonstrated a lack of adherence to cleaning protocols, resulting in unclean and unsanitary living conditions for residents in the affected rooms.
Deficient Food Storage, Preparation, and Equipment Sanitation
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and equipment cleanliness. The ice machine and its scoop holder had visible brown stains, indicating they were not thoroughly cleaned. Cooking equipment, including a large bread toaster, microwave, and toaster oven, showed significant buildup of dirt and dried food stains both inside and outside. Two baking pans were also heavily stained with food residue. Additionally, a tea dispenser containing tea was left uncovered, exposing it to potential air-borne contaminants. Further observations revealed that food items in the refrigerator, such as a container of pears and a glass container of milk, were not labeled or dated after being opened. Several large cans of fruit salad and beans in dry storage were also not dated with the month, day, and year of receipt. Interviews with the Dietary Manager and Administrator confirmed awareness of these issues, and facility policies reviewed required proper cleaning, sanitization, and labeling of food items, which were not followed as observed.
Failure to Protect Resident Privacy and Confidentiality of Medical Information
Penalty
Summary
Multiple instances were observed where staff failed to maintain the privacy and confidentiality of residents' personal and medical information. In one case, a piece of paper containing a resident's name, room number, and details about skin tears sustained during a fall was left unattended on top of a documentation cart in the hallway, visible to unauthorized individuals. The staff member present acknowledged that such information should not be left exposed and was unsure who was responsible for leaving it there. In another instance, a medication aide left a plastic medication packaging on top of a medication cart, which included a resident's name, medication details, prescription number, dosage, frequency, physician's order, diagnosis, and pharmacy name. The cart was unattended and facing the hallway, making the information accessible to anyone passing by. The aide admitted to leaving the packaging and recognized that it should not have been left exposed. Additional observations included a piece of paper with a resident's name and blood pressure left on a cart at the nurses' station, and a blister pack top with a resident's information left on a medication cart, both unattended and visible in the hallway. Staff interviews confirmed that these actions were contrary to facility policy and expectations regarding the confidentiality of resident information.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to five residents who required oxygen therapy, as evidenced by multiple deficiencies in the handling and administration of respiratory equipment. Observations revealed that several residents' nasal cannulas were not properly stored when not in use. Specifically, nasal cannulas were found coiled around oxygen tanks or attached to wheelchairs without being bagged, with the prongs exposed and touching surfaces. This was observed for multiple residents, and staff interviews confirmed that the cannulas should have been bagged to prevent respiratory infection, but this was not done during routine rounds. Additionally, the facility did not ensure that a humidifier bottle attached to an oxygen concentrator for one resident contained water. The humidifier bottle was observed to be empty while the resident was receiving oxygen therapy. Staff acknowledged that they had not checked the water level during their rounds, despite the purpose of the humidifier being to moisten the air and prevent irritation to the nasal passages. The facility also failed to display an "Oxygen In Use" sign outside the room of a resident receiving oxygen therapy. Staff interviews indicated that such signage is required to alert staff and visitors to the presence of oxygen and the associated fire hazards. Review of facility policies confirmed the requirements for proper storage of nasal cannulas, maintenance of humidifier water levels, and the posting of oxygen use signage, but these procedures were not followed as observed during the survey.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to established protocols during resident care. Certified Nursing Assistant (CNA) F did not perform hand hygiene before donning gloves, between glove changes, or after providing incontinent care to a female resident with a history of urinary tract infection and severe cognitive impairment. During the care process, the CNA changed gloves without sanitizing hands and handled soiled items before touching clean briefs and padding, further neglecting to wash hands after completing care. Licensed Vocational Nurse (LVN) C did not wear a gown while administering medications via gastrostomy tube to two residents who were on enhanced barrier precautions, as indicated by signage and care plans. Both residents had severe cognitive impairment and required feeding tubes for nutrition. Despite facility policy requiring the use of gloves and gowns during high-contact care for residents with indwelling medical devices, the LVN proceeded with medication administration without donning a gown. The Wound Care Nurse (WCN) J also failed to wear a gown while performing wound care on a male resident with a diabetic foot ulcer who was on enhanced barrier precautions. During the dressing change, the nurse touched the outside edge of the resident's foot and did not change gloves before handling the new dressing. These actions were inconsistent with facility policies on hand hygiene, glove use, and enhanced barrier precautions, as confirmed by staff interviews and policy reviews.
Failure to Obtain Physician Orders for Fall Prevention Equipment
Penalty
Summary
The facility failed to ensure that two residents' environments were free from accident hazards by not obtaining physician orders for safety equipment used for fall prevention. One resident, who was totally dependent for assistance with transfers, toileting, and bathing and had diagnoses including unsteadiness on feet, dementia, and muscle weakness, was observed with bolster pads on her bed. Review of her records showed no physician orders for the bolster pads, despite her care plan identifying her as high risk for falls and requiring a safe environment. Another resident, also totally dependent for assistance and with similar diagnoses including a history of falls and dementia, was observed with a scoop mattress on her bed. Record review indicated there were no physician orders for the scoop mattress, even though her care plan also identified her as high risk for falls. Interviews with the LVN and DON confirmed that both residents had equipment in use without the required physician orders, and that such equipment could restrict movement and potentially act as a restraint.
Failure to Ensure Accessible Call Lights for Dependent Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, as required by their care plans and facility policy. Both residents had severe cognitive impairments and were dependent on staff for activities such as transfer, toileting, dressing, and personal hygiene. Observations revealed that one resident's call light was found on the floor at the foot of the bed while she was in her wheelchair, and she was unaware of its location. In the other case, the call light was observed on the floor, coiled around an IV stand, while the resident was in bed and unable to communicate its location. Interviews with staff confirmed that call lights are essential for residents to request assistance, and that staff are responsible for ensuring call lights are within reach before leaving the room. In both cases, staff acknowledged that they had not ensured the call lights were accessible after providing care or administering medication. The facility's policy requires that each resident be provided with a means to call staff for assistance from their bed and other locations, but this was not followed in these instances. The deficiency was identified through direct observation, interviews with the residents and staff, and review of medical records and care plans. The lack of accessible call lights for these residents, both of whom were at risk for falls and dependent on staff, constituted a failure to reasonably accommodate their needs and preferences as outlined in their care plans and the facility's own policies.
Improper Perineal Care Technique During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate incontinent care to a female resident with a history of urinary tract infection and severe cognitive impairment. During an observed episode of care, the CNA cleaned the resident's perineal area and then proceeded to clean the resident's bottom by wiping from back to front multiple times, contrary to established infection control procedures. The CNA later acknowledged that the correct technique is to wipe from front to back to prevent urinary tract infections, but was unaware of her error during the care episode. The resident involved was always incontinent of bowel and bladder, as documented in her comprehensive assessment and care plan, which specified cleaning the perineal area with each episode of incontinence. Facility policy also outlined the correct procedure for perineal care, emphasizing the importance of wiping from the base of the labia towards and over the buttocks to prevent infection. Interviews with facility leadership confirmed that the expectation was for staff to follow these procedures to avoid cross-contamination and infection.
Failure to Verify G-Tube Placement and Residual Before Medication Administration
Penalty
Summary
Two residents with gastrostomy tubes (g-tubes) were not provided appropriate treatment and services to prevent complications of enteral feeding. Both residents had physician orders and care plans requiring verification of g-tube placement and checking for gastric residual prior to medication administration. On the observed date, an LVN prepared and administered medications via g-tube to both residents without performing these required checks. For the first resident, who had severe cognitive impairment and dysphagia, the LVN prepared the medication, dissolved it in water, and administered it through the g-tube after flushing, but did not verify tube placement or check for residual as ordered. The resident's care plan and physician orders specifically required these steps to be performed every shift. The second resident, who was unable to complete a cognitive interview and had a diagnosis of gastrostomy status, also received medications via g-tube from the same LVN without verification of tube placement or checking for residual, despite similar orders and care plan interventions. During interviews, the LVN acknowledged forgetting to perform the required checks and described the correct procedure, while the DON and ADON confirmed that staff are expected to verify g-tube placement and check residual before administering medications. The facility's policy also required confirmation of tube placement and checking gastric residual volume as part of enteral nutrition management.
Failure to Monitor and Manage Peripheral Artery Disease
Penalty
Summary
The facility failed to provide resident-centered care and services in accordance with professional standards of practice for a resident with a history of peripheral artery disease (PAD). The resident, a 78-year-old female with multiple comorbidities including metabolic encephalopathy, acute kidney failure, and type 2 diabetes mellitus, was admitted to the facility without a comprehensive care plan addressing her risk for skin integrity issues and PAD management. Despite the resident's known history of PAD, the facility did not implement preventative treatment orders or adequately monitor for signs and symptoms of PAD, such as diminished pedal pulses and skin discoloration. The facility's failure to conduct regular and thorough skin assessments contributed to the oversight of the resident's deteriorating condition. Weekly skin checks were not consistently performed, and when they were, they failed to identify significant changes in the resident's skin condition. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's skin issues, with several staff members unaware of the resident's PAD history and the associated risks. The resident's care plan did not reflect any focus on impaired skin integrity or PAD management, and interventions such as turning and repositioning were not effectively implemented. As a result of these deficiencies, the resident was transferred to the emergency department with mottled legs, abrasions on the toes, and absent distal pulses, eventually leading to a diagnosis of gangrenous skin of the toes. The facility's inadequate monitoring and documentation of the resident's condition placed her at unnecessary risk of serious complications, including infection and tissue necrosis. The lack of a coordinated approach to the resident's care and the failure to adhere to professional standards of practice were significant factors in the resident's adverse health outcomes.
Failure to Prevent Pressure Ulcers and Inadequate Skin Care
Penalty
Summary
The facility failed to ensure that a resident did not develop pressure ulcers unless clinically unavoidable and did not provide care and services consistent with professional standards to promote healing and prevent new pressure ulcers. The resident, a 78-year-old female with a history of metabolic encephalopathy, acute kidney failure, E. coli infection, and type 2 diabetes, was admitted to the facility with redness on the buttocks. Despite being at risk for pressure ulcers, the facility did not perform the required weekly skin assessments consistently, and the care plan did not reflect a focus on impaired skin integrity or risk of developing pressure injuries. The facility's inaction included failing to identify early signs of pressure injuries and implement interventions to prevent deep tissue pressure injuries in the sacral region. The resident was transferred to the hospital, where a deep tissue pressure injury and ischemic eschar were diagnosed. The facility's records showed inconsistencies in documenting skin assessments and interventions, with several staff members unaware of the resident's skin issues. The facility's policy required regular skin assessments and interventions, but these were not adequately followed. Interviews with staff revealed a lack of communication and coordination in monitoring and addressing the resident's skin condition. The wound care nurse and other staff members were not informed of the resident's skin issues, and there was a failure to document and notify appropriate personnel about changes in the resident's skin condition. The facility's failure to adhere to its policies and procedures for pressure ulcer prevention placed the resident at risk for complications, as evidenced by the hospital's findings upon the resident's transfer.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not create a care plan to address the risk of or actual altered skin integrity for the resident, who was admitted with a history of altered skin integrity. Additionally, the facility did not develop a care plan for the resident's peripheral artery disease (PAD), despite the resident's admission paperwork indicating a history of PAD. The resident, a 78-year-old female, was admitted to the facility with multiple diagnoses, including metabolic encephalopathy, acute kidney failure, E. coli infection, and type 2 diabetes mellitus. The resident required substantial assistance with activities of daily living and was always incontinent of bowel and bladder. Despite being at risk for developing pressure ulcers, the resident's care plan did not reflect a focus on impaired skin integrity or the risk of developing pressure injuries. The care plan goals were limited to preventing skin breakdown due to incontinence and maintaining intact skin related to fragile skin, without addressing the resident's specific needs for pressure injury prevention. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and updating of care plans. The Director of Nursing (DON) and other staff members were unaware of the deficiencies in the care plan, and there was no evidence of orders for pressure-relieving devices for the resident's heels. The facility's policy required care plans to include measurable objectives and timeframes, but this was not reflected in the resident's care plan. The failure to develop a comprehensive care plan could negatively impact the resident's quality of life and the quality of care received.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for three residents who required respiratory therapy. Observations revealed that the nasal cannulas (NC) for two residents were not changed and dated according to facility policy. Additionally, a registered nurse failed to change, date, and properly store the NC tubing and nebulizer mask for another resident. These lapses in care could potentially lead to respiratory infections and poor air quality for the residents. Resident #4, a female with a history of dementia and congestive heart failure, was observed with an undated humidifier water bottle and improperly stored nebulizer equipment. Her medical records indicated she was severely cognitively impaired and dependent on staff for all activities of daily living (ADLs). Despite having orders for regular oxygen therapy and nebulizer treatments, the equipment was not maintained according to the prescribed schedule, as evidenced by the undated and improperly stored items. Resident #5, who has dementia, asthma, and COPD, was observed with an undated NC and a nebulizer mask that was not stored in a bag. Her care plan included interventions for her respiratory conditions, but the equipment was not managed as required. Similarly, Resident #6, with a diagnosis of dementia and chronic respiratory failure, was found with undated NC tubing and a concentrator bottle. Interviews with staff revealed inconsistencies in following the facility's protocol for changing and dating respiratory equipment, contributing to the deficiencies noted.
Failure to Label and Store Enteral Feeding Supplies
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for two residents who were reviewed for feeding tubes. Specifically, the nursing staff did not label the enteral feeding formula and water bags with the date and time of administration for both residents. Additionally, the piston syringes used for flushing the feeding tubes were not stored in containers or dated, which could lead to potential risks such as tube obstruction and decreased hydration. Resident #3, a female with Huntington disease and dysphagia, was observed with an unlabeled enteral feeding formula bag and water bag. The piston syringe was found lying in a clear container without a date. The resident's care plan required PEG feeding and water flushes as ordered, but the lack of labeling and proper storage of the feeding supplies indicated a failure to adhere to these interventions. The resident was severely cognitively impaired and dependent on staff for care, highlighting the importance of staff compliance with feeding protocols. Resident #7, a female with multiple diagnoses including coronary artery disease and Barrett's esophagus, was also found with an unlabeled enteral feeding system. The piston syringe was improperly stored on a towel in a bedpan, and the feeding formula and water bags were not dated. Despite being cognitively intact, the resident was totally dependent on staff for activities of daily living. Interviews with nursing staff revealed that the failure to label and store the feeding supplies properly was due to oversight and workload, which could result in contamination and infection risks.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to immediately consult with a resident's physician and notify the resident's representative when there was a significant change in the resident's condition. This deficiency was identified for a resident who showed signs of altered mental status for at least 22 hours and was later diagnosed with severe sepsis at a local hospital. The resident, a male with paraplegia, osteomyelitis, and polyneuropathy, was admitted with stage 4 pressure ulcers and required IV medication and isolation for infectious disease. Despite these conditions, the facility did not document or report the resident's change in mental status to the physician or responsible party in a timely manner. Observations and interviews revealed that the resident exhibited symptoms such as hallucinations, yelling, and sweating, which were indicative of a significant change in condition. These symptoms were noted by various staff members, including CNAs and nurses, over a period of time. However, there was a lack of communication and documentation regarding these changes. The resident's hallucinations and altered mental status were reported by CNAs to an LVN, but the LVN did not document the assessment or notify the physician. The resident's condition continued to deteriorate, leading to a diagnosis of severe sepsis at the hospital. Interviews with staff members highlighted inconsistencies in the reporting and assessment of the resident's condition. Some staff members reported the resident's hallucinations and changes in condition, while others did not observe or document these changes. The facility's policy required that any significant change in a resident's condition be reported to the physician and family, but this was not adhered to in this case. The failure to promptly notify the physician and responsible party of the resident's altered mental status and potential infection risk resulted in a delay in appropriate medical intervention.
Removal Plan
- CCS in-serviced Administrator and DON on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. In-service covered when to notify the Physician/NP for a change of condition, discussed what categories fall under change of condition, the process for notification of Physician/NP, escalation of the communication process if the Physician/NP cannot be reached, and examples of significant changes. Competency was verified via quiz.
- Administrator and DON initiated in-services with the licensed nurses on change of condition policy and procedure to include comprehensive assessments and notification of Physician/NP. In-services covered when to notify the Physician/NP for a change of condition, discussed what categories fall under change of condition, the process for notification of Physician/NP, escalation of the communication process if the Physician/NP cannot be reached, and examples of significant changes. Competency was verified via quiz. Nursing staff will not be allowed to work until In-servicing has been completed.
- An audit was conducted by DON/Designee to identify other residents with potential change of condition. Via direct observation, staff interviews, and record review, no other residents were identified as having a change of condition. Medical Director was notified.
- In order to monitor current residents for potential risk, DON and CCS will monitor residents for change of condition for 30 days on all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition. DON compliance will be monitored weekly by CCS for 90 days. Thereafter, QA will monitor quarterly up to a year for compliance of change of condition, quality of care and abuse and neglect. If any issues are identified, the physician will be contacted for further medical management and family/POA of the same. The facility QA Committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Failure to Monitor and Report Resident's Condition Leads to Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services to a resident, leading to a significant decline in their physical and mental well-being. The resident, a 78-year-old male with complex medical conditions including paraplegia, osteomyelitis, and polyneuropathy, was admitted to the facility and was cognitively intact. Despite being at risk for constipation due to medications like Duloxetine and Tramadol, the facility did not administer the prescribed PRN medication MiraLax for constipation. The resident's bowel movements were not adequately monitored or documented, and significant changes in his condition, such as hallucinations and elevated heart rate, were not reported to the provider. The facility also failed to notify the provider of the resident's last known bowel movement and did not report significant abnormalities in bowel sounds as required by the care plan. The resident was admitted to the hospital with severe sepsis, chronic constipation, and fecal impaction after exhibiting altered mental status and other symptoms. The facility's staff, including nurses and CNAs, did not effectively communicate or document the resident's condition changes, leading to a delay in appropriate medical intervention. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition. The DON stated that changes in condition should be reported, but staff failed to do so. The MD was not informed of critical lab results or the resident's symptoms, which could have indicated severe complications. The facility's policies on bowel disorders and change of condition notifications were not followed, contributing to the resident's decline and subsequent hospitalization.
Removal Plan
- CCS inserviced DON on the prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz.
- DON/designee initiated inservices with the licensed nurses on prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- DON/designee initiated inservices with the CNAs/MA s on proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz.
- An audit of the 24-hour report and laboratory findings was conducted by DON/Designee to ensure Physician/NP has been notified timely.
- An audit of BM documentation was completed by DON/designee.
- Medical Director was notified.
- In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition and physician/np notification for all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition and to ensure timely notification of Physician/NP. DON compliance will be monitored weekly by CCS. Thereafter, QA will monitor quarterly for compliance of physician notification. The facility QA Committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
Failure to Notify Physician of Lab Results Leads to Resident Hospitalization
Penalty
Summary
The facility failed to promptly notify the physician of laboratory results for a resident, leading to a significant deficiency. The resident, a 78-year-old male with complex medical conditions including paraplegia, osteomyelitis, and polyneuropathy, was admitted to the facility. He was on medications such as Duloxetine and Tramadol, which have constipation as a common side effect. Despite being at risk for constipation and sepsis, the facility did not administer MiraLax as needed for constipation, nor did they document any interventions for constipation relief or notify the provider of the resident's condition. On a specific day, the resident exhibited altered mental status, hallucinations, and other symptoms indicative of a serious condition. STAT lab results were ordered and received, showing abnormal values, but the facility failed to notify the physician promptly. The resident was later admitted to the hospital with severe sepsis and chronic constipation, where a CT scan revealed a large rectal stool ball and colonic stool burden, indicating fecal impaction. Interviews with staff revealed a lack of communication and documentation regarding the resident's bowel movements and changes in condition. The Director of Nursing (DON) and other staff members were not informed of the resident's constipation or other symptoms, and the physician was not notified of the STAT lab results in a timely manner. This oversight placed the resident at high risk for serious complications, including sepsis.
Removal Plan
- CCS inserviced DON on the prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz.
- DON/designee initiated inservices with the licensed nurses on prompt or timely review of laboratory results, lab policy and procedure to include the lab tracking system, lab orders, receiving lab results, and proper follow up and notifications. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- An inservice was initiated on the proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- DON/designee initiated inservices with the CNAs/MA s on proper documentation of resident bowel function and reporting any important changes to the nurse. Competency was verified via quiz. Nursing staff will not be allowed to work until inservicing has been completed.
- An audit of the 24-hour report and laboratory findings was conducted by DON/Designee to ensure Physician/NP has been notified timely.
- An audit of BM documentation was completed by DON/designee.
- Medical Director was notified.
- In order to monitor current residents for potential risk, DON, and CCS will monitor residents for change of condition and physician/np notification for all residents via Triage Log. The purpose of this log is to monitor residents with acute changes in condition and to ensure timely notification of Physician/NP. DON compliance will be monitored weekly by CCS. Thereafter, QA will monitor quarterly for compliance of physician notification. The facility QA Committee will meet weekly to review compliance with the plan of action. If no further concerns are noted, will continue to monitor as per routine facility QA Committee.
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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