Ignite Medical Resort Fort Worth, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 6301 Oakmont Blvd, Fort Worth, Texas 76132
- CMS Provider Number
- 676449
- Inspections on file
- 43
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Ignite Medical Resort Fort Worth, Llc during CMS and state inspections, most recent first.
A resident with ESRD on peritoneal dialysis, prior possible peritonitis, stroke, diabetes, and heart failure was care planned for nightly PD with nursing interventions to monitor for infection and dialysis complications, but the facility did not ensure that PD supplies and a functioning cycler were available, resulting in missed treatments. The resident and CNA reported that the family performed PD hookups and the resident sometimes disconnected herself, while nursing staff did not monitor the dialysis process beyond basic vitals and site checks. The DON and RN stated that admission was contingent on self- or family-performed PD, that the facility had no emergency PD equipment, and that staff were not trained or authorized to connect, disconnect, or troubleshoot PD, despite facility PD training materials assigning nurses responsibility for clinical surveillance and recognition of peritonitis and fluid overload. The resident was later hospitalized with abdominal pain, nausea, vomiting, and suspected peritonitis after missed PD treatments and lack of supplies.
A nurse failed to secure and properly dispose of an IV antibiotic medication prescribed for a resident with a knee infection. The medication, which required refrigeration, was left unattended on a door handle in a resident hallway, exposed to sunlight and not locked away as required. Staff interviews confirmed the medication was not handled according to policy, and it was only destroyed after being discovered by another nurse.
Three residents with complex medical needs were not accurately coded in their MDS assessments for BiPAP/CPAP use and, in one case, a PICC line for IV therapy. Observations showed respiratory equipment was not cleaned or stored as ordered, and care plans did not consistently address these treatments. Staff interviews confirmed that MDS assessments were not completed accurately, and the facility's policy on assessment accuracy could not be reviewed.
Several residents requiring respiratory care did not receive services consistent with professional standards, as BiPAP/CPAP masks were improperly stored or not cleaned, and oxygen tubing was not dated or discarded as required. Staff interviews confirmed lapses in following protocols for cleaning, storage, and documentation of respiratory equipment, and care plans and medical records were found to be incomplete or inaccurate regarding respiratory support.
A resident with multiple risk factors for skin breakdown developed a Stage 3 pressure ulcer and several deep tissue injuries after staff failed to implement timely preventive care, properly use pressure-relieving devices, and communicate skin concerns. Inconsistent skin assessments, lack of wound care consultation, and improper use of offloading wedges contributed to the deficiency.
Several residents were not treated with dignity when one was left exposed in bed with her gown improperly closed, and three others with indwelling urinary catheters did not have privacy covers on their drainage bags. Staff were aware of the requirements for privacy and dignity but did not ensure these measures were in place, despite facility policies and training mandating such practices.
A resident with severe cognitive and physical impairments did not consistently receive scheduled bed baths and grooming, as evidenced by disheveled and matted hair and exposed clothing in photographs. Additionally, an LVN was observed standing while feeding the resident, contrary to facility policy and training, increasing the risk of choking. Documentation and family reports highlighted lapses in personal hygiene and feeding assistance, despite the resident's need for substantial staff support.
Several residents with indwelling urinary catheters did not have securement devices in place as required by care plans and physician orders, despite staff being aware of the policy and having received training. Observations and record reviews confirmed that catheter tubing was not anchored, and staff could not explain the omission, resulting in noncompliance with facility protocol.
Two residents in the facility did not receive wound care treatments as per physician orders, with multiple blanks on the TAR and MAR indicating missed treatments. Resident #1, with a history of cellulitis and diabetes, and Resident #4, with muscle wasting and diabetes, both had incomplete wound care documentation. Interviews with staff confirmed that blanks on the TAR meant treatments were not done, and there was a lack of documentation explaining these omissions.
A facility failed to provide necessary wound care for a resident with a stage 3 pressure ulcer, as a blank entry on the TAR indicated a missed treatment. Interviews with staff confirmed that the treatment was not performed, risking infection and delayed healing. The facility's policy requires accurate documentation of physician orders, which was not followed.
A facility failed to administer an albuterol inhaler to a resident with COPD and asthma as per physician orders, resulting in blanks on the MAR for two days. Staff interviews revealed inconsistencies in documenting medication administration, with some staff unsure of the implications of blanks on the MAR/TAR. The facility's policy required accurate transcription of physician orders, which was not followed, leading to a deficiency in providing necessary respiratory care.
The facility failed to properly store, label, and date food items in the kitchen, with missing temperature logs for refrigerators. Additionally, not all items on the steam table were temped, and the dishwasher thermometer was malfunctioning, risking foodborne illness and improper sanitization.
A facility failed to replace a resident's oxygen tubing weekly as ordered, risking respiratory compromise and infection. The resident, with conditions like COPD and a history of pneumonia, had tubing dated weeks old despite orders for weekly changes. Staff interviews revealed inconsistencies in practice and documentation, highlighting risks of infection and decreased oxygen levels.
A facility failed to regularly inspect bed frames and mattresses, resulting in a resident having an oversized bariatric mattress on a standard twin bed frame. This mismatch caused discomfort and potential safety hazards, as the mattress did not fit properly and slipped when the resident attempted to sit. Despite family concerns, the issue was not addressed until observed by surveyors, highlighting a lapse in maintenance and communication among staff.
A resident with multiple medical conditions did not receive prescribed pain medications before wound care, leading to increased pain during an ileostomy bag change. The nursing staff failed to verify and document the administration of pain medication, contrary to the facility's pain management policy. The resident exhibited signs of pain, and the DON acknowledged the risk of medication errors due to delayed documentation.
A resident with an ileostomy experienced skin excoriation and pain due to inadequate care and pain management. The resident's care plan was not followed, leading to improper ileostomy bag changes and lack of pain medication administration. Nursing staff failed to document and verify pain management, resulting in the resident enduring unnecessary pain during procedures.
A facility failed to follow prescribed enteral feeding orders for a resident, setting the water flush rate at 150 mL every 4 hours instead of the ordered 200 mL. The LVN responsible admitted to not checking updated orders, risking dehydration for the resident. Interviews with facility leadership highlighted expectations for staff to verify and follow orders, with the DON noting the LVN's previous non-compliance issues.
A medication cart was left unlocked and unattended by an LVN in a hallway, allowing potential unauthorized access to medications. The LVN was unable to maintain visual contact with the cart while attending to a resident, and an ADON moved the cart without realizing it was unlocked. Interviews confirmed awareness of the policy requiring carts to be locked when out of sight, and recent training had been conducted to reinforce this requirement.
A facility failed to maintain accurate medical records for a resident's PICC line care, lacking physician orders for dressing changes and management. The oversight occurred during the resident's readmission, with nursing staff assuming orders were in place. The ADON, responsible for monitoring such orders, was absent, contributing to the error. The facility's policy requires complete documentation of orders, but this lapse could delay care and treatment.
A resident with VRE and MRSA infections was put at risk due to RN H's failure to follow infection control protocols during ileostomy care. RN H did not perform hand hygiene or change soiled gloves, handled clean supplies with contaminated gloves, and improperly managed supplies in an isolation room. Interviews revealed RN H's nervousness and lack of experience contributed to these lapses, and documentation showed incomplete training records.
A facility failed to provide adequate pain management for three residents, leading to prolonged high pain levels and distress. Despite being prescribed pain medications, residents experienced delays and ineffective pain relief, with staff failing to notify physicians or properly assess pain levels. Interviews revealed inconsistencies in pain management practices, contributing to the deficiency.
The facility failed to ensure accurate administration of medications for a resident with severe cognitive impairment and multiple comorbidities. LVN A and MA B administered BiDil despite the resident's blood pressure being outside the physician-ordered parameters, without notifying the medical staff. The care plan did not include BiDil administration, and the facility's policy on vital sign documentation was not followed.
Failure to Ensure Safe Peritoneal Dialysis and Supply Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring peritoneal dialysis (PD) received dialysis services consistent with professional standards of practice. The resident was an adult female with end-stage renal disease, prior possible peritonitis, stroke, type 2 diabetes, and heart failure, who was admitted with an active need for PD from 6 p.m. to 6 a.m. Her care plan identified dialysis needs and directed staff to monitor the PD catheter site for redness or drainage, report cloudy effluent, inadequate drainage or inflow problems, sudden weight changes, shortness of breath, abdominal pain, fever, and signs of infection. The care plan also documented that PD would be completed independently by the resident or guest and that the resident would supply her own supplies. Despite this, the facility did not ensure that dialysis supplies, including a functioning cycler, were available on specific days, and the resident missed PD treatments on those days. The resident reported that she performed her own dialysis and that nursing staff did not monitor her during the dialysis process or check on her while it was occurring. She stated that earlier in the week she did not have the equipment needed to do her dialysis because the cycler she was using was broken and she was waiting for her family to bring supplies from home. She did not request supplies from the facility because her family usually brought enough supplies for about five days at a time. She acknowledged missing two or three days of dialysis in the past and stated that nurses took her vital signs, listened to her chest, and sent her for chest x-rays after she had missed days of dialysis, and that she later experienced vomiting and was sent to the hospital. CNA interview indicated that the family hooked the resident up to the dialysis machine and left the facility, and that if the family was late returning, the resident disconnected herself from the machine. The DON stated that admission was contingent on the resident or family performing all aspects of PD independently and that facility nurses were responsible only for monitoring, which she described as reminding the resident to connect and disconnect from the machine. She reported that the facility did not have emergency PD equipment on site, that the resident missed two days of dialysis during a winter storm because the family did not bring supplies and the cycler was broken, and that the resident had stated she was fine with missing those treatments. The DON also stated that when a treatment was missed, the PCP was to be notified, and that the PCP was notified after missed treatments and the resident was assessed and sent for x-rays. RN staff reported they were not trained to connect, monitor, or disconnect the PD machine, and that their monitoring consisted of checking the catheter site for redness or drainage, taking vital signs, and confirming that the resident connected and disconnected herself, with the resident entering her own dialysis data into the machine. The facility’s PD inservice materials and an undated admission acknowledgment form showed that the facility did not provide staff-assisted PD, placed responsibility for supplies and equipment on the resident/family, and limited staff responsibilities to general clinical surveillance and vital signs, while prohibiting staff from performing PD connections or troubleshooting PD equipment. The resident was later admitted to the hospital with abdominal pain, nausea, vomiting, and suspected peritonitis, and the PCP stated that the resident not having supplies to properly do dialysis placed her at risk of becoming septic.
Failure to Secure and Properly Dispose of IV Medication
Penalty
Summary
A deficiency occurred when a nurse failed to properly store and secure an intravenous (IV) antibiotic medication prescribed for a male resident with a history of infection and inflammatory reaction due to an internal knee prosthesis. The resident was receiving IV medications, including vancomycin and ceftriaxone, for a knee infection and required enhanced barrier precautions and regular monitoring of his PICC line and dressing. The resident was cognitively intact and required varying levels of assistance with activities of daily living. On the day of the survey, the resident's PICC line medication, labeled as requiring refrigeration, was found left unattended on the exit door handle at the end of the resident hall, exposed to sunlight. The medication was not secured in a locked compartment as required by state and federal regulations. The nurse responsible for administering the medication admitted to leaving it on the door handle with the intention of destroying it later but forgot about it until notified by another staff member. The medication was subsequently destroyed by pouring it down the toilet after being retrieved by another nurse. Interviews with facility staff, including the LVN, MDS nurse, ADON, DON, and CNA, confirmed that the medication was not stored or discarded according to facility policy and regulatory requirements. Staff acknowledged that the medication should have been immediately secured and destroyed in the designated medication room container. The incident was recognized as a failure to follow proper medication storage and destruction protocols, which could have allowed unauthorized access to the medication.
Failure to Accurately Code MDS Assessments for Respiratory and IV Treatments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status and treatments of three residents. Specifically, the MDS assessments for these residents did not properly code for the use of BiPAP/CPAP treatments, and in one case, did not code for a PICC line as ordered by the physician. Observations revealed that BiPAP/CPAP masks were not stored or cleaned according to physician orders, with masks found on the floor, on nightstands, or in drawers unbagged, and residents reported that staff had not cleaned or bagged their equipment. The MDS coordinator stated that coding for a non-invasive mechanical ventilator was considered sufficient, but specific sections for BiPAP and CPAP were left blank, and the PICC line was not documented as required. The residents involved had significant medical histories, including chronic heart failure, obstructive sleep apnea, COPD, osteomyelitis, sepsis, asthma, and chronic respiratory failure. All three residents were cognitively intact and required varying levels of assistance with activities of daily living. Physician orders and care plans indicated the need for BiPAP/CPAP treatments and, in one case, a PICC line for IV antibiotic therapy. However, these treatments were not consistently documented in the MDS assessments, and care plans did not always address the respiratory equipment or IV therapy as required. Interviews with facility staff, including the MDS coordinator and DON, confirmed that the responsibility for accurate and timely completion of MDS assessments rested with the MDS coordinator, with RN review for accuracy. Despite this, the assessments were not completed accurately to reflect the residents' care and treatments. The facility's policy for conducting accurate assessments was requested but could not be reviewed due to technical issues with the electronic copies provided.
Deficient Respiratory Care Practices and Equipment Handling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such care, as evidenced by multiple deficiencies in the handling, cleaning, and storage of respiratory equipment. Observations revealed that several residents' BiPAP/CPAP masks were not stored according to facility protocol for sanitation. For example, one resident's mask was found on the floor, while another's was left unbagged on a nightstand. Additionally, a resident reported that their mask had not been cleaned since admission. These actions were inconsistent with both physician orders and facility policy, which require daily cleaning and proper storage of respiratory devices in clean, dated bags when not in use. Further deficiencies were noted in the management of oxygen therapy equipment. One resident was observed wearing a nasal cannula (NC) with tubing that was not dated, and an additional, used NC was found on the resident's wheelchair seat. The resident was unable to recall when the tubing was last changed. Facility policy and physician orders specified that oxygen tubing should be changed weekly and dated, and that used tubing should be discarded immediately to maintain a clean clinical environment. Interviews with staff confirmed that these procedures were not consistently followed, and that lapses in discarding old equipment and dating new tubing had occurred. Record reviews for the affected residents showed that care plans and medical orders addressed the need for respiratory support, including BiPAP/CPAP use and oxygen therapy. However, documentation was incomplete or inaccurate in some cases, with missing or improperly coded information regarding the type of respiratory support provided. Staff interviews further confirmed that there was a lack of adherence to established protocols for cleaning, storage, and documentation of respiratory equipment, which could compromise the quality of care provided to residents requiring respiratory support.
Failure to Provide Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide necessary treatment and preventive care for a resident at risk for pressure ulcers, resulting in the development of multiple pressure injuries. Upon admission, the resident had several risk factors, including diabetes, stroke, hemiplegia, malnutrition, and severe cognitive impairment, and was dependent on staff for mobility and self-care. Initial assessments documented redness to the heels, groin, buttocks, and eschar to the left big toe, but the wound care team was not notified, and preventive interventions such as pressure-relieving devices were not implemented in a timely manner. The care plan included interventions like barrier cream, frequent repositioning, and skin monitoring, but there was a lack of consistent follow-through and communication among staff regarding these interventions. Over the course of the resident's stay, staff failed to monitor and respond to early signs of pressure injury, particularly on the heels and sacrum. Weekly skin assessments inconsistently documented skin issues, and the wound care nurse did not recognize or escalate concerns about developing wounds. The wound care nurse also demonstrated a lack of knowledge regarding wound staging and did not consult the wound medical doctor when significant skin changes were identified. Observations and interviews revealed that pressure offloading devices, such as wedges and heel protectors, were not properly placed or used, and staff were unclear about their correct application and purpose. Additionally, there was inadequate documentation and monitoring of repositioning and offloading interventions. As a result of these failures, the resident developed a Stage 3 pressure ulcer on the sacrum and multiple deep tissue injuries to the heels and toes, which were not present on admission. The facility's own policies and professional standards of practice for pressure ulcer prevention, including timely assessment, use of pressure-relieving devices, and appropriate staff communication, were not followed. These deficiencies were identified through observations, interviews, and record reviews, and placed residents at risk for new or worsening pressure ulcers.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity and respect for four residents by not ensuring proper coverage of their bodies and by not providing privacy covers for indwelling urinary catheter drainage bags. One resident, a female with severe cognitive impairment, hemiplegia, and total dependence on staff for activities of daily living, was observed in photographs provided by her family to be lying in bed with her gown pulled down, exposing her right shoulder and upper chest. Staff interviews confirmed that the resident required total care and that such exposure would be considered a violation of resident rights and dignity. The staff stated that rounds were performed every two hours, but they were unaware of the exposure until shown the photographs by the surveyor. Additionally, three other residents with indwelling urinary catheters were observed without privacy covers on their catheter drainage bags. Observations revealed that the catheter bags were visible and not covered as required by facility policy and standard practice. Staff interviews confirmed knowledge of the requirement for privacy covers, but they could not explain why the covers were not in place at the time of observation. The care plans for these residents did not consistently include interventions to ensure catheter bag privacy, and the staff responsible for catheter care acknowledged their responsibility but failed to implement the required measures. Facility policy reviews indicated that all staff were required to attend annual in-service training on resident rights and abuse prevention, and that catheter drainage bags should be covered with dignity covers. Despite these policies and training, the observed failures resulted in residents being exposed or having their catheter bags visible, which could compromise their dignity and psychosocial well-being. The surveyors did not receive a copy of the facility's Resident Rights Policy during their visit.
Failure to Provide Consistent ADL Care and Proper Feeding Technique
Penalty
Summary
The facility failed to provide consistent care and assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. The resident, who had a history of severe cognitive impairment, stroke with resulting hemiplegia and hemiparesis, aphasia, dysphagia, end-stage renal disease, and dependence on dialysis, required substantial to maximal assistance with all ADLs, including bathing, grooming, oral hygiene, dressing, and feeding. According to the care plan and ADL schedule, the resident was to receive bed baths three times per week and assistance with grooming and hygiene. However, documentation and family interviews indicated that bed baths and grooming were not provided consistently according to the schedule, and the resident was observed with disheveled and matted hair on multiple occasions. Photographs provided by the family showed the resident with exposed upper chest and shoulder, and her hair in poor condition, suggesting lapses in personal care and dignity. Additionally, the report documents that a Licensed Vocational Nurse (LVN) was observed standing while feeding the resident, contrary to facility policy and in-service training, which require staff to be seated while feeding residents to reduce the risk of choking and aspiration. The LVN acknowledged having received training on proper feeding techniques but admitted to standing while feeding the resident on at least one occasion, as confirmed by video footage provided by the family. Interviews with staff and administration confirmed that the expectation is for staff to sit while feeding residents, and that standing while feeding poses a risk to resident safety. The facility's own records, including shower sheets and grievance logs, corroborated the family's concerns about inconsistent ADL care. The resident's family filed a grievance on the day of discharge, citing inadequate assistance with personal hygiene and grooming. Staff interviews revealed that while some ADL care was documented, there were discrepancies between staff accounts and the family's observations, particularly regarding the resident's grooming and the manner in which feeding assistance was provided. The facility's policies require individualized care based on comprehensive assessment, but the observed and reported deficiencies indicate that these standards were not consistently met for this resident.
Failure to Secure Indwelling Urinary Catheters as Ordered
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, specifically by not ensuring the use of catheter securement devices (straps) to prevent pulling or tugging of the catheter tubing. Observations on multiple residents revealed that the catheter tubing was not secured with a strap, as required by facility policy and physician orders. For example, one resident was observed in bed with the catheter tubing lying across the leg and no securement device in place, while another resident had the catheter tubing hanging through pajama pants and attached to a drainage bag on a walker, also without a securement device. Record reviews showed that care plans and physician orders for these residents included instructions for catheter care, such as anchoring the tubing with a strap and checking skin integrity. However, these interventions were not consistently implemented. In one case, the care plan did not include specific interventions for positioning the catheter bag and tubing or ensuring a securement device was in place. Additionally, medication administration records did not always reflect that catheter care orders were followed as written. Interviews with staff confirmed that they were aware of the need for catheter securement devices and privacy covers for drainage bags, but could not explain why these were not in place for the affected residents. Staff described their training and responsibilities regarding catheter care, but acknowledged the absence of securement devices during the survey. The facility's own policy required the use of securement devices to prevent movement and reduce infection risk, but this was not adhered to for the residents reviewed.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards and the comprehensive person-centered care plan for two residents. Resident #1, a male with a history of cellulitis, metabolic encephalopathy, and type 2 diabetes mellitus, did not receive wound care treatments as per physician orders. The treatment records for Resident #1 showed multiple blanks on the Treatment Administration Record (TAR) and Medication Administration Record (MAR), indicating that the prescribed treatments, including the application of betadine and wound dressings, were not consistently administered. The progress notes did not provide explanations for these omissions. Resident #4, a male with muscle wasting, traumatic ischemia, and type 2 diabetes mellitus, also did not receive wound care as ordered. The TAR for Resident #4 showed a blank entry for a scheduled wound dressing change, and the progress notes did not document any reason for the missed treatment. Interviews with the Wound Care Nurse and other staff revealed that blanks on the TAR typically indicated that treatments were not performed, and there was a lack of documentation to justify these omissions. The Director of Nursing (DON) and other staff members confirmed that the absence of signatures on the MAR and TAR meant treatments were not completed. The facility's policy required that all physician orders be documented and transcribed accurately, and any unclear orders be clarified before implementation. However, the failure to adhere to these protocols resulted in residents not receiving necessary wound care, potentially impacting their health and recovery.
Failure to Document and Perform Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with pressure ulcers, as evidenced by the lack of a documented wound dressing change for a resident with a stage 3 pressure ulcer on the right buttock. The resident, an elderly female with a history of osteomyelitis, sepsis, and muscle weakness, was admitted to the facility with specific physician orders for daily wound care. However, a review of the Treatment Administration Record (TAR) revealed a blank entry on a specific date, indicating that the treatment was not completed as ordered. Interviews with the wound care nurse, RN, LVN, and the Director of Nursing (DON) confirmed that a blank on the TAR signifies that the treatment was not performed. The wound care nurse and RN emphasized the importance of signing off on the TAR to ensure treatments are administered and documented. The DON and Administrator acknowledged the risk of infection and delayed healing due to the failure to document and perform the treatment. The facility's policy requires that all physician orders be promptly and accurately transcribed and documented, which was not adhered to in this instance.
Failure to Administer Albuterol Inhaler as Ordered
Penalty
Summary
The facility failed to provide necessary respiratory care to a resident, specifically in administering an albuterol inhaler as per physician orders. The resident, who had been diagnosed with chronic obstructive pulmonary disease (COPD), asthma, and heart failure, did not receive the prescribed albuterol inhaler on two consecutive days. The medication administration record (MAR) for these days contained blanks, indicating that the medication was not administered, and there was no documentation in the progress notes explaining the omission. Interviews with facility staff revealed a lack of clarity and consistency in documenting medication administration. The Director of Nursing (DON) acknowledged that a blank on the MAR or treatment administration record (TAR) meant the medication was either not administered or not signed off. Staff members, including a wound care nurse and registered nurse, emphasized the importance of signing off on the MAR/TAR to confirm that care was provided. However, one licensed vocational nurse (LVN) was unsure of the implications of a blank on the MAR/TAR. The facility's policy required prompt and accurate transcription of physician orders, but this was not adhered to in this case, leading to a failure in providing the necessary respiratory care to the resident.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Observations revealed multiple instances of improperly stored food in the facility's kitchen, including items in the refrigerator and freezer that were not labeled or dated. For example, a medium stainless steel pan of brown gravy and a small plastic container labeled grilled chicken were found without proper dating or covering. Additionally, temperature logs for the reach-in refrigerators were missing entries for several days, indicating a lack of consistent monitoring. Further deficiencies were noted in the handling of food temperatures on the steam table. During an observation, a staff member failed to take the temperature of all items on the steam table, such as white gravy and beef patties, because they were not listed on her sheet. The Dietary Manager confirmed that all items should be temped before serving. This oversight could lead to serving food at unsafe temperatures, posing a risk of foodborne illness to residents. The facility also failed to ensure the proper functioning of the dishwasher thermometer. A dietary aide admitted to not knowing how to take the temperature of the dish machine and simply copied previous entries on the temperature log. When the Dietary Manager checked the dishwasher, it was found to be reading incorrect temperatures, which could result in dishes not being properly sanitized. The Maintenance Director was unaware of the issue until it was brought to his attention, despite a recent repair to the dishwasher's temperature module.
Failure to Replace Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not replacing the resident's oxygen tubing weekly as per physician's orders. The resident, a male with moderately impaired cognition, was receiving continuous oxygen therapy due to conditions including anemia, chronic obstructive pulmonary disease, and a history of lumbar spinal fusion surgery. The resident had been hospitalized for hypoxia and sepsis secondary to pneumonia before being transferred to the facility for skilled nursing care. Despite orders to change the oxygen tubing every Sunday night shift, observations revealed that the tubing and water bottle were not changed as required, with dates on the equipment indicating they had not been replaced since 10/20/24. Interviews with facility staff, including the DON and LVNs, confirmed that the oxygen tubing should be changed weekly and as needed to prevent infection and ensure proper oxygen delivery. However, discrepancies were noted in the documentation and actual practice, as the MAR indicated the tubing was changed on specific dates, but observations contradicted these records. Staff members expressed surprise upon learning of the outdated tubing and acknowledged the risks associated with not changing the equipment, such as infection and decreased oxygen saturation levels. The facility's policy on O2 hygiene also emphasized the importance of changing tubing in accordance with physician orders to prevent infection.
Failure to Inspect and Maintain Proper Bed Equipment
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails, leading to potential entrapment hazards for a resident. Specifically, the facility did not identify that a resident's twin-sized bed had an oversized bariatric mattress, which did not fit properly within the bed frame. This oversight was discovered during an observation and interview, where it was noted that the mattress had a large depression causing discomfort and pain to the resident, and it slipped when the resident attempted to sit down. The resident, who was cognitively intact but had several medical conditions including repeated falls and muscle weakness, was unable to rest properly due to the ill-fitting mattress. Despite family members raising concerns about the mattress size to nursing staff, the issue was not addressed until it was observed by surveyors. The facility's maintenance and housekeeping procedures failed to identify and rectify the mismatch during room preparation and regular maintenance checks. Interviews with various staff members, including CNAs, the ADON, and the Maintenance Director, revealed a lack of communication and follow-through in addressing the mattress issue. Staff members acknowledged the risks associated with having a bariatric mattress on a standard twin bed frame, such as potential falls and discomfort, but the problem persisted until it was brought to the attention of the facility's administration during the survey.
Inadequate Pain Management for Resident During Wound Care
Penalty
Summary
The facility failed to provide adequate pain management for a resident requiring such services, as observed during a survey. The resident, a male with multiple medical conditions including an abscess of the liver, Type 2 diabetes, Parkinsonism, and a non-traumatic perforation of the intestine, was not administered prescribed pain medications, Acetaminophen and Tramadol, before undergoing wound care. This oversight was noted despite the resident's care plan, which included interventions for pain management and wound care, indicating a need for scheduled pain medication evaluation and administration. On the day of the observation, the resident was found to be in pain during an ileostomy bag change, a procedure known to cause discomfort due to skin excoriation. The resident expressed uncertainty about receiving pain medication prior to the procedure, and the attending nurse, RN H, did not verify the administration of pain medication before proceeding with the wound care. The resident exhibited signs of pain, such as moaning and grimacing, during the procedure, which was not alleviated by the use of a handheld fan as suggested by the nurse. Interviews with the nursing staff revealed a lack of documentation and verification regarding the administration of pain medication. RN G admitted to not documenting the administration of Tylenol and was unaware of the last administration time of Tramadol. The Director of Nursing (DON) acknowledged the risk of medication errors due to delayed documentation and emphasized the importance of pain assessment and management. The facility's policy on pain management highlighted the need for optimal pain assessment and management, which was not adhered to in this instance.
Inadequate Ileostomy Care and Pain Management
Penalty
Summary
The facility failed to provide appropriate ileostomy care for a resident, leading to skin excoriation around the stoma site and stool leakage. The resident, a male with multiple medical conditions including Parkinsonism, diabetes, and a history of intestinal perforation, had an ileostomy that required regular care. The care plan for the resident included interventions to maintain skin integrity and manage pain, but these were not adequately followed. During an observation, it was noted that the resident's skin was bright red and raw around the ileostomy site, indicating improper care. The resident experienced significant pain during the ileostomy bag change, and it was revealed that pain medication was not administered as required before the procedure. The nurse responsible for the care did not verify the administration of pain medication, leading to the resident enduring unnecessary pain. Interviews with the nursing staff revealed a lack of documentation and communication regarding pain management. The nurse believed pain medication had been administered, but there was no documentation to confirm this. The Director of Nursing acknowledged the risk of medication errors due to delayed documentation and emphasized the importance of pain assessments. The facility's policy on pain management was not adhered to, resulting in the resident experiencing increased pain during care.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via enteral feeding received the appropriate treatment and services according to professional standards. Specifically, the facility did not adhere to the prescribed water flush rate for the resident's feeding tube. The resident, a male with multiple diagnoses including encephalopathy, gastrostomy status, and adult failure to thrive, was observed with a water flush rate set at 150 mL every 4 hours instead of the ordered 200 mL every 4 hours. This discrepancy was noted during an observation and interview with an LVN, who admitted to not checking the updated orders due to familiarity with the resident's previous regimen. The LVN acknowledged the oversight, stating that the physician had changed the order the day before, and failing to adjust the water flush rate could lead to dehydration. Interviews with the ADON and DON revealed that it was expected for nursing staff to verify and follow orders as prescribed, and failure to do so could delay care. The DON mentioned that the LVN had previous non-compliance issues and would be terminated. The facility's policy on physician orders emphasized the importance of accurately transcribing and following orders, highlighting the procedural lapse in this case.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation on A hallway, it was noted that LVN C left a medication cart unlocked and unattended while attending to a resident in their room. The medication cart was placed in the doorway, but LVN C was unable to maintain visual contact with it while she was in the resident's bathroom and at the bedside, reconnecting a feeding tube. This oversight was further compounded when ADON B moved the unlocked cart to retrieve a dropped hand sanitizer bottle, without realizing it was unlocked. Interviews with LVN C revealed that she was aware of the requirement to lock the medication cart when it was out of sight but failed to do so. She acknowledged the potential risk of residents gaining unauthorized access to medications, which could be harmful. ADON B also admitted to not checking if the cart was locked when she moved it and emphasized the importance of ensuring medication carts are secured to prevent unauthorized access to medications, including over-the-counter drugs. The DON and ADM both reiterated the facility's policy that medication carts must be locked when not in use and out of sight. They confirmed that recent in-service training had been conducted to reinforce this policy, and staff were expected to adhere to it. The facility's policy on medication storage clearly states that medication carts should be locked when not attended by authorized personnel, highlighting the importance of maintaining security and safety in medication management.
Deficiency in Maintaining Accurate Medical Records for PICC Line Care
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding physician orders for PICC line dressing and care. The resident, a male with multiple complex medical conditions including liver abscess, Type 2 diabetes, and Parkinsonism, was readmitted to the facility without proper documentation of PICC line management orders. This oversight was identified during a review of the resident's records, which did not include necessary orders for PICC line dressing changes and IV management, despite the resident receiving IV medications for an infection. Interviews with nursing staff revealed that the omission of PICC line orders occurred during the resident's readmission process. RN G, who readmitted the resident, assumed that all necessary orders were in place and did not verify or input the PICC line orders. The Assistant Director of Nursing (ADON) was responsible for monitoring such orders but was not present, contributing to the oversight. The Director of Nursing (DON) acknowledged the error and emphasized the importance of checking orders before procedures to prevent missing critical care steps. The facility's policy on physician orders requires that orders be documented completely and transcribed accurately by nursing staff. However, the failure to obtain and document PICC line orders for the resident led to a deficiency in care, as the necessary procedures for PICC line maintenance were not followed. This lapse in documentation and order management could potentially delay care and treatment for residents, as noted by the facility's administration.
Infection Control Lapses During Ileostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of RN H during the care of a resident with multiple complex medical conditions, including VRE and MRSA infections. During an observation, RN H did not perform hand hygiene or change soiled gloves while changing the resident's ileostomy bag. This oversight occurred despite the resident being on contact isolation, which required strict adherence to infection control protocols to prevent the spread of infection. RN H gathered supplies for the procedure but left them unattended on a treatment cart in the hallway, which was against the facility's infection control policy. Upon entering the resident's room, RN H did not clean the bedside table or remove the resident's drinks, which posed a risk of contamination. Throughout the procedure, RN H used soiled gloves to handle clean supplies and apply medication, further compromising the sterile field and increasing the risk of infection transmission. Interviews with the ADON and DON revealed that RN H was aware of the correct procedures but failed to follow them due to nervousness and lack of experience with ileostomy care. The facility's infection control policies were not adhered to, as evidenced by RN H's actions and the lack of documentation of her completion of relevant in-service training. The DON and ADON acknowledged the risk of contamination and infection spread due to these lapses in protocol.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to a deficiency in care. Resident #1, a cognitively intact female with multiple fractures and pain due to orthopedic devices, did not receive her prescribed oxycodone in a timely manner upon admission. Despite her complaints of severe pain, she was only given acetaminophen initially, and her pain levels remained high for several days without appropriate intervention or physician notification. Resident #2, also cognitively intact, suffered from high pain levels due to fractures and other conditions. Despite being prescribed tramadol and oxycodone, her pain levels remained elevated, and she reported feeling neglected by the nursing staff. She experienced delays in receiving pain medication and was not effectively monitored or assessed for pain relief, leading to increased distress and depression. Resident #3, with a history of shoulder dislocation and other painful conditions, experienced persistent high pain levels despite receiving various pain medications. The facility's change in pharmacy contributed to delays in medication administration, and staff failed to notify physicians about the ineffectiveness of the pain management plan. Interviews with staff revealed inconsistencies in pain assessment and management practices, contributing to the residents' prolonged suffering.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that assured accurate administration of medications for a resident with severe cognitive impairment and multiple comorbidities, including heart failure and kidney failure. Licensed Vocational Nurse (LVN) A and Medication Aide (MA) B did not follow physician orders when administering the heart medication BiDil on several occasions, despite the resident's blood pressure being outside the physician-ordered parameters. This failure was not documented as a medication administration record (MAR) error, and the medical staff was not notified of the deviations from the prescribed parameters. The resident's care plan did not include the administration of BiDil, and the electronic MAR and vitals record showed that the medication was administered even when the resident's blood pressure readings were outside the specified parameters. Interviews with the medical staff, including the nurse practitioner (NP) and the medical doctor (MD), revealed that they were not informed about the resident's blood pressure being outside the parameters and the subsequent administration of BiDil. Both LVN A and MA B admitted to potentially making mistakes in documenting the administration of the medication. The facility's policy required vital signs to be taken and documented before administering medications with specific parameters. The Regional Nurse confirmed that the staff should have checked the resident's blood pressure and notified the MD if it was outside the parameters. The failure to follow these procedures could place residents at risk of not receiving the therapeutic benefits of their medications, potentially leading to harm or a decline in health.
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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