Immanuel's Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 4515 Village Creek Rd, Fort Worth, Texas 76119
- CMS Provider Number
- 676052
- Inspections on file
- 50
- Latest survey
- January 7, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Immanuel's Healthcare during CMS and state inspections, most recent first.
A resident with intact cognition, a history of stroke, seizures, non-Alzheimer’s dementia, and a PASARR-positive status for intellectual disability alleged that the Administrator told him to “shut up” and mind his business during a facility event. The facility’s abuse policy required protection of residents, confidentiality of allegations, and prohibition of harassment or interference with investigations, but during a PASARR meeting the MDS nurse brought the Administrator—who was the alleged perpetrator and Abuse Coordinator—into the room after the allegation was made. The Administrator then directly confronted and argued with the resident, denied the allegation, and was reported by another staff member to have claimed the resident was fabricating the complaint in retaliation, demonstrating the facility’s failure to implement its abuse policies and procedures.
A resident with intact cognition and a PASARR-positive status for intellectual disability alleged that the Administrator and Activity Director told him to "shut up" and "mind your business" during a facility event after he complained about non-residents attending. The allegation surfaced during a PASARR meeting, where the MDS nurse brought in the Administrator—who was also the alleged perpetrator and Abuse Coordinator—to confront the resident in front of others. The Administrator denied the allegation and argued with the resident, while the Activity Director was not present. The DON later conducted the abuse investigation but did not interview the resident, did not perform a safe survey with him, and did not interview all staff present at the meeting, relying instead on statements from the Administrator, Activity Director, and MDS nurse. Despite facility policy stating all abuse allegations would be investigated, the investigation was deemed unfounded without a direct resident interview or comprehensive witness interviews, resulting in a failure to demonstrate a thorough investigation of the abuse allegation.
The facility did not maintain adequate documentation or active orders for dialysis care for three residents, including missing post-dialysis weights and communication from the dialysis center. Staff interviews revealed inconsistent processes for tracking dialysis documentation, and care plans were not fully implemented in practice. Despite residents attending their dialysis appointments, the facility's records did not reflect the required monitoring and communication.
Surveyors identified multiple deficiencies in food storage and handling, including unsealed, expired, and dented food items found in the kitchen's dry storage, refrigerator, and freezer areas. Staff interviews revealed a lack of awareness regarding these issues, despite existing policies and training on proper food storage, labeling, and the FIFO method.
A facility failed to consistently and accurately reconcile and document the administration of Lorazepam 0.5mg for a resident with dementia and on hospice care. Surveyors found discrepancies in the medication count, broken blister pack seals, and improper documentation by nursing staff. Facility policy for handling and disposing of controlled substances was not followed, leading to an inaccurate account of the medication.
A resident with multiple chronic conditions was found to have nystatin topical powder stored unsecured in her room and used during personal care, contrary to facility policy requiring all medications to be kept in locked carts and administered by nursing staff. Facility staff were unaware of the medication's presence in the room, and interviews confirmed this practice was not in line with established procedures.
A resident with a new diagnosis of bipolar disorder was not referred for a required PASRR Level II Evaluation. The initial PASRR Level I Screening did not indicate a mental illness, but after the bipolar disorder diagnosis was documented, no further PASRR Screening or Evaluation was completed as required. The MDS Coordinator confirmed the oversight and noted the absence of a facility policy on PASRR Evaluations.
A nurse failed to wear required PPE while administering medication and tube feeding to a resident on enhanced barrier precautions, despite clear signage and policy. The nurse acknowledged awareness of the precautions and the risk of infection, and the DON confirmed that staff had been trained on infection control protocols.
A resident accused an LVN of physical abuse, but the LVN failed to report the allegation to the facility's abuse coordinator or Administrator as required by Texas law. The resident, with a history of dementia and other mental health conditions, had a BIMS score indicating intact cognition. Despite the facility's policy requiring immediate reporting and investigation of abuse allegations, the incident was not documented or reported, placing residents at risk of ongoing abuse.
The facility failed to maintain an infection prevention and control program, leading to multiple instances of non-compliance with infection control protocols. Staff did not perform hand hygiene or change gloves during resident care and medication administration, and medication rooms were found in unsanitary conditions, risking contamination and infection spread.
The facility failed to maintain an effective pest control program, resulting in a significant fly infestation in two hallways. Multiple residents reported and were observed to be affected by the flies, which were seen landing on their skin, clothing, and personal items. Despite monthly pest control visits and the use of blue light traps, the problem persisted, particularly in the dining room and courtyard.
The facility failed to provide necessary grooming and personal hygiene services for two residents who were unable to perform ADLs independently. One resident had long fingernails despite family requests for trimming, and another had an unkempt beard, flaky skin, and long, dirty nails despite requesting care from the staff. Interviews revealed inconsistencies in the facility's nail care procedures.
The facility failed to ensure proper storage and handling of medications in two medication rooms, with a refrigerator found at 56 degrees Fahrenheit and inadequate lighting. Staff were unaware of the correct temperature range and the status of the medication rooms, leading to potential risks for medication integrity.
Failure to Follow Abuse Policy When Resident Reported Verbal Abuse by Administrator
Penalty
Summary
The deficiency involves the facility’s failure to implement its written abuse policy and procedure after a resident made an allegation of verbal abuse against the Administrator. The facility’s undated Abuse/Neglect policy stated that the facility would take necessary measures to protect residents from harm during and following an abuse investigation, that allegations of abuse would remain confidential, and that harassment and interfering with an investigation would result in disciplinary action. Despite this, when a resident reported during a PASARR meeting that the Administrator had told him to “shut up, mind your business and don’t say anything” during a prior fall festival, the Administrator was brought into the same meeting and directly confronted the resident about his allegation. The resident involved was an adult male with intact cognitive skills for daily decision-making, with diagnoses including stroke, seizures, and non-Alzheimer’s dementia, and a PASARR-positive status related to intellectual disability. During interview, he reported that at a fall festival he had complained that it was not fair that the festival was not just for residents, and that both the Administrator and Activity Director told him to “shut up, mind your business and don’t say anything,” though he believed the Activity Director was joking and the Administrator was serious. He did not report the allegation until his PASARR meeting, where he stated that the Administrator had spoken to him in this manner. He reported that when the Administrator came into the meeting, she denied saying this, repeatedly put her hand up to stop him from talking, argued with him about what she had said, and remained in the room until just before the other staff left. Staff interviews confirmed that the Administrator, who was also the Abuse Coordinator, was summoned into the PASARR meeting after the resident made the allegation. The MDS nurse stated she brought the Administrator into the meeting because she felt the accused had the right to face their accuser, despite acknowledging that this could cause fear of retaliation and make the resident feel unsafe reporting concerns. The ECC Service Coordinator reported that the Administrator came into the meeting, negated the resident’s claim, stated he was fabricating the allegation due to retaliation, and argued back and forth with him, without leaving the room after the allegation was made. The Administrator herself acknowledged that it was not facility policy to allow the alleged perpetrator to question the resident, and that staff were supposed to contact the DON or corporate staff if she was named as the alleged perpetrator. This sequence of events demonstrated that the facility did not follow its own abuse policy regarding protection of residents, confidentiality of allegations, and prevention of harassment or interference with the investigation process.
Failure to Thoroughly Investigate Resident’s Verbal Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by Resident #1. Resident #1 was an adult male with intact cognitive skills for daily decision-making, with diagnoses including stroke, seizures, and non-Alzheimer’s dementia, and a PASARR-positive status related to intellectual disability. During a PASARR meeting on 12/02/25, he reported that during a Fall Festival on 10/15/25, the Administrator and Activity Director told him to “shut up,” “mind your business,” and “don’t say anything” after he complained that the festival was not just for residents. He stated that the Activity Director was joking but that the Administrator “meant it” and took it “to a whole new level.” He had not reported the allegation before that meeting. When Resident #1 voiced the allegation during the PASARR meeting, the MDS Nurse left the meeting and brought the Administrator into the room, explaining she believed the accused had the right to face their accuser. The Administrator, who was the alleged perpetrator and also the Abuse Coordinator, entered the meeting and directly engaged with Resident #1 about his allegation. Resident #1 reported that when he tried to speak, the Administrator repeatedly put her hand up to stop him from talking, and that she argued with him about what she had said. The ECC Service Coordinator, who was also present, stated that the Administrator negated the resident’s claim, said he was fabricating the allegation in retaliation, and argued back and forth with him. The Activity Director was not present at this meeting and was not confronted by the resident. The subsequent facility investigation, led by the DON with assistance from Corporate Staff, did not include an interview with Resident #1 and did not include a safe survey with him, despite his being the alleged victim. The DON acknowledged she did not interview the resident and instead relied on statements from the MDS Nurse and Administrator, as well as denials from the Administrator and Activity Director. She also did not interview other individuals who were present at the PASARR meeting, such as the Therapy Director or ECC Service Coordinator. Corporate Staff later stated he was unaware that the resident had not been interviewed and that other meeting participants had not been interviewed, and he acknowledged that failure to complete a thorough investigation could result in missed information. The facility’s abuse/neglect policy stated that all investigations of abuse would be investigated, but the investigation report for this allegation did not reflect that Resident #1 was interviewed or given a safe survey, and the DON stated she did not identify any issues with her investigation. The Administrator stated that facility staff were supposed to contact the DON or Corporate Staff if she was named as the alleged perpetrator, but in this case she personally went into the PASARR meeting and spoke with the resident about his allegation. The MDS Nurse later recognized that having a resident face the alleged perpetrator could cause fear of retaliation and make it feel unsafe to report concerns. Corporate Staff stated that the MDS Nurse should have notified the DON instead of bringing in the Administrator. Despite these circumstances, the investigation concluded the allegation was unfounded, without direct resident interview or comprehensive witness interviews, resulting in a failure to have evidence that the alleged violation was thoroughly investigated as required by facility policy. The DON characterized Resident #1 as a “fabricator of instances and stories” and stated he was care planned for this behavior, and she reported that both the Administrator and Activity Director denied the allegation. The Administrator reported that the resident had made multiple calls to the state in the past and was upset about not being allowed to sell items out of his room. However, these characterizations and prior behaviors were not balanced by a documented, direct interview with the resident about the specific allegation, nor by interviews with all individuals present at the PASARR meeting. The Provider Investigation Report did not document a resident interview or safe survey, and the DON admitted she was “probably supposed to interview the resident” but did not know what the policy required without reading it. As a result, the facility lacked documentation that it had thoroughly investigated the verbal abuse allegation in accordance with its abuse/neglect policy.
Failure to Document and Coordinate Dialysis Care
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received services consistent with professional standards, their care plans, and their individual goals and preferences. Specifically, for three residents reviewed, there was inadequate documentation regarding offsite hemodialysis treatments at an ESRD unit. Record reviews revealed that care plans identified the need for regular dialysis and associated interventions, such as monitoring access sites and documenting post-dialysis weights and communication from the dialysis center. However, there were no active orders for dialysis treatment or care of dialysis access sites in the residents' records, and required documentation such as post-dialysis weights and communication forms from the dialysis center were missing for extended periods. Interviews with staff, including LVNs and the DON, confirmed that there was no consistent process for collecting and maintaining dialysis communication forms from the dialysis center. Staff reported that forms were sometimes lost or not returned, and there was no centralized system for tracking these documents. Additionally, the DON acknowledged that orders were not always reactivated when residents returned from the hospital, and the admitting nurse was responsible for ensuring orders were in place. The CNA responsible for pre- and post-dialysis weights indicated that her schedule did not always align with residents' return from dialysis, leading to missed documentation. Despite residents reporting that they attended all scheduled dialysis appointments and had no concerns about their care, the facility's records did not reflect adequate documentation of dialysis treatments, post-dialysis monitoring, or communication with the dialysis center. The lack of active orders and missing documentation could result in incomplete monitoring and care for residents receiving dialysis, as evidenced by the findings during the survey.
Deficient Food Storage and Handling Practices Identified in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection of the kitchen's dry storage, refrigerator, and freezer areas, surveyors observed multiple food items that were unsealed and exposed to air, including containers of cream cheese icing, white rice, powder milk, a gallon of Caesar salad dressing, and several boxes of frozen foods. Additionally, expired food items were found in both the dry storage and refrigerator areas, such as a container of jalapeno peppers and a container of pickles. A dented can of lima beans was also found stored with other canned goods in the dry pantry area. Interviews with the Dietary Supervisor (DS) and dietary staff revealed that they were unaware of the presence of expired, unsealed, and dented food items in the kitchen. The DS stated that all kitchen staff were responsible for ensuring food items were sealed, labeled, and checked for expiration dates, and that dented cans should be removed from shelves and placed in a designated area. Staff interviews confirmed that they had received training on food storage, labeling, and the FIFO (First In, First Out) method, but were not aware of the deficiencies identified during the survey. A review of the facility's food storage policy indicated that all foods and supplies should be stored appropriately to protect them from contamination, with procedures for checking in and storing items, and ensuring older products are used first. The FDA Food Code was also referenced, requiring packaged food to be labeled and protected from contamination. Despite these policies and staff training, the facility did not ensure compliance, resulting in the presence of unsealed, expired, and dented food items in the kitchen.
Failure to Accurately Reconcile and Document Controlled Medication Administration
Penalty
Summary
The facility failed to establish and implement a consistent and accurate system for reconciling controlled medications, specifically Lorazepam 0.5mg, for a resident with a history of non-Alzheimer's dementia, hypertension, and senile degeneration of the brain who was on hospice care. The resident had physician orders for Lorazepam to be administered as needed for anxiety or agitation. During a surveyor's observation, the medication blister pack for Lorazepam was found to have two broken seals: one with the pill still inside and taped over, and another with the pill missing. The documented count was 12 pills, but only 11 were present in the blister pack. Interviews with nursing staff revealed that the nurse responsible for administering the medication did not notice the missing pill or the broken blister seals until it was brought to her attention by the surveyor. The nurse admitted to making a documentation error, initially recording that two pills were given instead of one, and later making a late entry to correct the mistake. The nurse also failed to sign the narcotic count sheet at the time of administration. The DON confirmed that facility policy requires any broken blister pack seal to result in the pill being discarded by two nurses, and that taping over a broken seal is not acceptable. However, this protocol was not followed in this instance. Further interviews with other nursing staff indicated that narcotic counts were performed at shift changes, but the broken blister and missing pill were not detected during these counts. The facility's policy on controlled substances outlines detailed procedures for handling, documenting, and reconciling controlled medications, but these procedures were not consistently followed, resulting in an inaccurate account of the controlled drug and a failure to maintain proper records of receipt and disposition.
Medication Storage Policy Not Followed
Penalty
Summary
A deficiency occurred when a resident was found to have a bottle of nystatin 100,000 units topical powder stored in her room, rather than in a locked medication or treatment cart as required by facility policy and professional standards. The resident, who is cognitively intact and has multiple medical diagnoses including hypertension, morbid obesity, hyperlipidemia, and COPD, kept the medication in her drawer and would either self-administer or request staff assistance for application. During a bed bath, the resident handed the medication to a CNA for application, revealing that the medication was not secured. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that medications are to be stored in locked carts and that only nurses should apply medicated powders. The LVN and DON were unaware that the resident had medication in her room, and both acknowledged that this was against facility policy. Review of the facility's medication storage and labeling policy further confirmed that all medications must be stored in locked compartments and only accessed by authorized personnel.
Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR Evaluation after the resident received a new diagnosis of bipolar disorder. Initially, the resident's PASRR Level I Screening did not indicate the presence of a mental illness, intellectual disability, or developmental disability, and therefore, a Level II Evaluation was not completed at that time. However, after the resident was later diagnosed with bipolar disorder, there was no evidence in the medical record that a subsequent PASRR Screening or Evaluation was conducted as required. The resident in question was an older female admitted with multiple diagnoses, including sick sinus syndrome, heart failure, and, later, bipolar disorder. The MDS Assessment confirmed the bipolar disorder diagnosis, but the facility did not initiate the necessary PASRR Level II Evaluation following this new diagnosis. The MDS Coordinator acknowledged that the evaluation should have been completed and was unable to provide a reason for the omission, as she was not employed at the facility during that period. Additionally, the facility did not have a policy related to PASRR Evaluations and relied on following state guidelines.
Failure to Use PPE During High-Contact Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
A deficiency was identified when LVN B failed to don personal protective equipment (PPE) prior to performing a high-contact care activity for a resident on enhanced barrier precautions. Specifically, LVN B prepared and administered medication and tube feeding to a male resident with a history of bipolar disorder, hemiplegia, dysphagia, and gastronomy status, without wearing the required PPE. The resident's care plan and room signage indicated the need for enhanced barrier precautions, and a PPE cart was available outside the room. Despite this, LVN B only performed hand hygiene before entering the room and did not use gloves or a gown while accessing the resident's feeding tube. During interviews, LVN B acknowledged awareness of the resident's precaution status and admitted she should have donned PPE before providing care. She also recognized that failure to use PPE could put the resident at risk for infection. The DON confirmed that staff were expected to use appropriate PPE for residents on enhanced barrier precautions and that staff had been in-serviced on infection control protocols. Facility policy required the use of gloves and gowns for high-contact activities, including device care such as feeding tubes, but this protocol was not followed in this instance.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a staff member, LVN A, in a timely manner as required by Texas law. The incident involved a resident who accused LVN A of punching her on the shoulder. Despite being aware of the allegation, LVN A did not report it to the facility's abuse coordinator or the Administrator. This failure to report the incident placed residents at risk of ongoing abuse and potential harm. The resident involved in the incident was an elderly female with a history of dementia, bipolar disorder, anxiety disorder, and paranoid personality disorder. She had a BIMS score indicating intact cognition and required assistance with daily activities. The resident had a history of verbally abusive behaviors and had been involved in a resident-to-resident altercation, leading to a recommended discharge from the facility. Despite these behaviors, the allegation of abuse by LVN A was not documented in the resident's progress notes or the facility's incident log. Interviews with facility staff, including LVN A, the DON, the Administrator, and the Owner, revealed a lack of awareness and action regarding the abuse allegation. LVN A admitted to not reporting the incident and was unable to define abuse and neglect during the interview. The DON and Administrator were unaware of the allegation until informed by a State Surveyor. The facility's policy required immediate reporting and investigation of abuse allegations, but this protocol was not followed, resulting in a deficiency in the facility's handling of the situation.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, leading to multiple instances of non-compliance with infection control protocols. For Resident #21, a CMA did not perform hand hygiene before and after checking the resident's blood pressure and administering medication. This lapse in protocol was acknowledged by the CMA, who admitted to forgetting to perform hand hygiene, thereby risking the spread of infection to the resident, who has multiple health issues including stroke, high blood pressure, and diabetes. For Resident #35, who was on contact isolation for C-diff, a CNA failed to follow proper infection control procedures during incontinent care. The CNA used dirty gloves to retrieve and apply barrier cream from her pocket, contaminating both herself and the resident. The CNA admitted to being aware of the isolation precautions but failed to change gloves or perform hand hygiene, thereby risking the spread of infection. Additional deficiencies were observed with Resident #38 and Resident #48, where LVNs failed to perform hand hygiene and change gloves during medication administration and blood sugar checks, respectively. The medication rooms were also found to be in unsanitary conditions, with personal belongings and unclean surfaces, further risking contamination. Interviews with staff and administration revealed a lack of adherence to infection control policies, despite ongoing training and in-services on the subject.
Fly Infestation in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant fly infestation in two hallways (F and H). Multiple residents reported and were observed to be affected by the flies, which were seen landing on their skin, clothing, and personal items. Residents expressed frustration and concern about the unsanitary conditions, with some even resorting to using their own fly swatters. The issue was particularly noticeable in the dining room and courtyard, where flies were observed to be a persistent problem. Interviews with residents and staff revealed that the fly problem had been ongoing, especially during warmer weather. Residents had repeatedly raised their concerns with the Administrator and Maintenance Supervisor, but no effective solutions had been implemented. Staff members acknowledged the presence of flies and attributed it to residents keeping juice and fruit in their rooms, as well as the proximity of horse stables to the facility. Despite the use of blue light traps and monthly pest control visits, the problem persisted. The Maintenance Director, who was new to the facility, confirmed that pest control services were conducted monthly and that additional measures were being considered. However, the Administrator and Maintenance Director both cited the nearby horse stables as a significant source of the fly infestation. The facility's Pest Control Policy indicated that frequent treatment and additional visits should be conducted when a problem is detected, but these measures had not been effective in resolving the issue. Residents continued to experience discomfort and unsanitary conditions due to the persistent fly problem.
Failure to Provide Adequate Grooming and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for two residents who were unable to perform activities of daily living (ADLs) independently. Resident #38, who had diagnoses including cerebral infarction, anxiety disorder, aphasia, and hemiplegia, was observed with long fingernails despite his family member's request to the nursing staff to have them trimmed. The resident's BIMS score indicated significant memory problems, and he was rarely or never understood, requiring modified independence in decision-making regarding daily tasks. The family member confirmed that the staff had not trimmed the resident's fingernails despite multiple requests. Resident #33, who had diagnoses including acute and chronic respiratory failure, atrial fibrillation, and pulmonary hypertension, was observed with an unkempt beard, flaky skin, and long, dirty fingernails and toenails. The resident, who had a BIMS score indicating no memory problems and was independent in decision-making, reported that he had requested nail care from the nursing staff two weeks prior, but no action had been taken. Interviews with the ADON, CNA, DON, and Administrator revealed inconsistencies and lack of clarity in the facility's nail care procedures, contributing to the observed deficiencies in personal hygiene and grooming for these residents.
Medication Storage and Lighting Deficiencies
Penalty
Summary
The facility failed to implement procedures for the safe storage and handling of medications in two medication rooms. Specifically, the refrigerator in one medication room was found to be at 56 degrees Fahrenheit, which is outside the safe temperature range for storing medications. The refrigerator contained unopened and unexpired insulin vials, insulin pens, vaccines, suppository medications, and cold packs. The refrigerator door insulation was partially torn off, and the staff responsible for monitoring the temperature logs were unaware of the correct temperature range. Additionally, the lighting in the medication rooms was inadequate, with multiple ceiling lights not functioning, which was not noticed by the staff until pointed out by the surveyors. The ADON and Maintenance Director were also unaware of the proper temperature range and the status of the medication rooms, respectively. Interviews with the RN, ADON, Maintenance Director, DON, and Administrator revealed a lack of awareness and communication regarding the proper storage conditions for medications. The night shift nursing staff was responsible for monitoring and documenting refrigerator temperatures, but there was no clear understanding of the acceptable temperature range or the risks associated with improper storage. The facility's policy on medication labeling and storage did not address the issue of lighting in the medication rooms, and the DON stated that there was no risk with lighting as the medication room was not used for preparing medications. The Administrator emphasized the importance of following facility policies and procedures to prevent the spread of infection.
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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