Life Care Center Of Haltom
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 2936 Markum Dr, Fort Worth, Texas 76117
- CMS Provider Number
- 675935
- Inspections on file
- 48
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Life Care Center Of Haltom during CMS and state inspections, most recent first.
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans that incorporated ordered respiratory treatments and equipment care for three residents. One resident with obstructive sleep apnea had MD orders detailing BIPAP settings and cleaning, but the care plan only addressed assistance with applying and removing the mask and did not include BIPAP use, storage, or cleaning, and the mask and hose were observed with a greasy, cloudy film on the nightstand. A second resident with COPD and multiple fractures had MD orders for continuous oxygen and scheduled changes and labeling of oxygen tubing and humidifier bottles, but the care plan did not address tubing change frequency or labeling, and the resident was observed wearing an undated nasal cannula. A third resident with obstructive sleep apnea and asthma had MD orders for BIPAP and respiratory monitoring, yet the care plan only addressed hypertension and omitted BIPAP use, storage, and cleaning. The DON and Administrator acknowledged responsibilities for care plan accuracy but did not explain why these respiratory treatments and tasks were not reflected in the care plans, despite a facility policy requiring timely, interdisciplinary, person-centered care plan updates.
The facility failed to follow physician orders, care plans, and internal policy for cleaning, storing, changing, and labeling respiratory equipment for three residents requiring BIPAP and oxygen therapy. One resident’s BIPAP mask for sleep apnea was left unbagged on a nightstand with visible greasy buildup after staff removed it, contrary to expectations for cleaning and storage. Another resident on continuous oxygen via nasal cannula had oxygen tubing and a humidifier bottle that were not changed or dated as ordered, and the resident reported the tubing had not been changed since admission. A third resident using BIPAP for sleep apnea had a mask stored unbagged in a drawer with visible oil and moisture buildup, and her care plan did not address BIPAP use, cleaning, or storage, despite staff and DON stating that masks should be cleaned and bagged and oxygen equipment changed and dated at least weekly and as needed.
An LVN observed a male resident with a history of wandering and visual impairment in the bed area of a female roommate during night rounds, after which the roommate loudly alleged that her roommate had been molested. The alleged victim, an older female with multiple comorbidities and moderately impaired cognition requiring extensive ADL assistance, was found asleep with undisturbed covers, and the LVN performed only a general visual check without a full head-to-toe assessment. Despite being trained on abuse reporting and facility policy requiring immediate notification of suspected abuse, the LVN did not report the allegation to the Administrator or DON during the night and instead only noted it on a pad, believing abuse had not occurred. The Administrator did not learn of the allegation until late the following morning when the roommate reported it directly, resulting in a failure to report the alleged abuse within the required two-hour timeframe.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities, as required by regulations.
A resident with intact cognition and multiple diagnoses reported that a CNA asked for and received money, leading to an incomplete investigation by the facility. The facility did not document interviews with other staff or residents, nor did it provide evidence of a thorough investigation as required by policy.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and intervention for pressure ulcer management.
Two residents with cognitive impairment and existing pressure ulcers were not consistently provided with pressure-relieving devices or repositioned as required by their care plans and facility policy. Observations showed both residents lying on their backs without support, despite orders and staff knowledge that repositioning and use of wedges were necessary to prevent further skin breakdown.
Two residents requiring enhanced barrier precautions due to wounds and skin breakdown did not have appropriate signage or PPE available in or outside their rooms. Staff were observed preparing to provide care without PPE until prompted, and interviews revealed inconsistent maintenance of infection control measures following room changes, despite active orders and facility policy.
A resident with severe cognitive impairment and left-sided paralysis was found by a family member to have significant bruising on the forearm, which was reported to the DON and an RN. Despite facility policy requiring immediate reporting of injuries of unknown origin, the injury was not documented or reported to the administrator or state authorities as required. Staff attributed the injury to combative behavior, and no timely investigation or notification occurred, resulting in a failure to follow abuse and neglect policies.
A resident with severe cognitive impairment and left-sided paralysis was found with a significant bruise of unknown origin on the left forearm. The family reported the injury to the DON and an RN, but the incident was not reported to the state or the administrator as required by policy. Staff interviews indicated uncertainty about the cause, and the DON determined the injury was not suspicious for abuse, so no report was made. The facility failed to follow required procedures for reporting alleged violations, including injuries of unknown source.
Two residents did not receive adequate supervision or proper assistive device use to prevent accidents. One resident with severe cognitive impairment and a history of falls was left unattended after requesting to be put to bed, resulting in an unwitnessed fall and injury. In another case, a resident with hemiplegia and total dependence for transfers was moved using a mechanical lift by only one staff member on two occasions, contrary to policy requiring two staff for such transfers.
A resident with severe cognitive impairment and left-sided paralysis developed a significant bruise on the left forearm, which was reported by a family member to the DON and an RN. Despite this, there was no documentation in the EHR, no progress notes, and no assessment of the bruise, even though x-rays were ordered. Staff interviews confirmed that required documentation and incident reporting were not completed, contrary to facility policy.
A facility failed to provide appropriate post-dialysis care for a resident with end-stage renal disease, as evidenced by missing documentation of vital signs and incomplete dialysis communication forms. Despite staff awareness and training, the necessary monitoring and documentation were not consistently performed, potentially placing the resident at risk of complications.
The facility failed to ensure proper pharmaceutical services, with deficiencies in medication management across multiple carts and storage areas. Insulin pens on two medication carts were not labeled with opening dates, and expired medications were found on two other carts. Additionally, a discrepancy in the reconciliation of a resident's morphine solution was discovered, with the narcotic log showing more than what was actually present. These oversights were acknowledged by the staff responsible for medication management.
A resident's privacy was compromised during IV medication administration when RN A failed to close the door or pull the privacy curtain, leaving the resident exposed. The resident was cognitively intact and receiving treatment for a skin infection. RN A admitted to forgetting to provide privacy due to nervousness, and the DON confirmed the expectation for staff to ensure privacy during care.
A facility failed to label IV medication bags with the date, time, and nurse's initials, risking medication errors for a resident. Despite training, staff oversight led to unlabeled bags, as confirmed by observations and interviews with nursing staff and the DON.
A facility failed to maintain infection control when a CNA entered a COVID-positive resident's room without wearing an N95 mask or eye protection, despite clear signage and available PPE. The resident, with severe cognitive impairment, was under contact and droplet precautions. Interviews with staff confirmed the expectation for PPE compliance, and the CNA had missed recent infection control training.
A resident's DNR order was found invalid due to improper dating, with mismatched signature dates between the resident and the physician. This discrepancy led to conflicting code status information in the resident's care plan and face sheet, potentially risking the resident's end-of-life wishes. The Social Worker and MDS Coordinator acknowledged the issue, and the DON confirmed the invalidity of the document.
Failure to Integrate Respiratory Treatments and Equipment Care Into Comprehensive Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and time frames for residents receiving respiratory treatments and equipment. For three residents reviewed, the care plans did not fully address their respiratory therapy needs as reflected in physician orders and actual use of equipment. The facility’s own policy required timely, person-centered comprehensive care plans that are reviewed and revised by an interdisciplinary team when resident conditions or treatments change. For one resident with obstructive sleep apnea and a BIMS score indicating moderate cognitive impairment, the MDS documented respiratory therapy and active diagnoses including obstructive sleep apnea. The care plan noted altered respiratory status related to sleep apnea and included a goal that the resident would have no signs or symptoms of poor oxygen absorption, with an intervention to assist with putting on and taking off the BIPAP mask at bedtime and in the morning. However, the care plan did not address BIPAP use, storage, or cleaning, despite MD orders specifying BIPAP settings, use while sleeping or napping, and detailed cleaning instructions for the mask and reservoir. During observation, the resident’s BIPAP mask and hose were seen on the nightstand with a small greasy and cloudy film from daily facial use, and the resident stated staff had removed the mask that morning. For a second resident with COPD, multiple fractures, and a BIMS score indicating moderate cognitive impairment, the MDS and MD orders documented continuous oxygen via nasal cannula and specific orders to change oxygen tubing, nebulizer circuit, and humidifier bottle on a set schedule, with labeling when changed and as needed when soiled. The admission care plan addressed COPD with respiratory failure, included a goal for optimal breathing patterns, and listed interventions such as elevating the head of bed and monitoring for signs and symptoms of respiratory infection and acute respiratory insufficiency, as well as documenting oxygen settings. The care plan did not address the frequency of oxygen tubing changes or labeling, even though MD orders required these tasks. During observation, the resident was seen in bed wearing an undated nasal cannula and denied concerns with the oxygen machines. For a third resident with intact cognition, obstructive sleep apnea, and asthma, the MDS documented use of a wheelchair and walker and dependence on staff for several ADLs. The care plan addressed hypertension, including administration of antihypertensive medications, monitoring for side effects, and obtaining blood pressure readings prior to medication administration. Section O of the MDS reflected special treatments and procedures, and MD orders included monitoring for shortness of breath when lying flat, PRN nebulized albuterol for shortness of breath and wheezing, and an order for BIPAP with specified settings to be applied upon availability. The resident’s care plan did not address BIPAP use, storage, or cleaning. In interviews, the DON stated clinical staff were responsible for updating care plans and that the EMR provided prompts, and acknowledged that residents were receiving respiratory treatments per MD orders but did not explain why these treatments were not reflected in the care plans. The Administrator stated the DON was responsible for monitoring and ensuring resident care tasks were addressed and accurate, and that care plans address residents’ individual medical needs and treatments, but did not provide additional information regarding the non-compliance with care plans. The facility’s written policy on comprehensive care plans and revision, dated and reviewed as noted in the record, stated that the facility would ensure timeliness of each resident’s person-centered comprehensive care plan and that the plan would be reviewed and revised by an interdisciplinary team knowledgeable about the resident and their needs, with resident and representative involvement. The policy further stated that the facility should monitor residents over time to identify changes that may warrant updates to the care plan, and when such changes occur, the care plan should be reviewed and updated to reflect changes in care delivery, including adding interventions, updating goals or problem statements, or adding short-term problems, goals, and interventions. Despite this policy, the care plans for the three residents did not incorporate the specific respiratory treatments, equipment care, and related tasks ordered by physicians and documented in the medical record.
Failure to Clean, Store, Change, and Label Respiratory Equipment per Orders and Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care consistent with professional standards, physician orders, and care plans for multiple residents using BIPAP and oxygen therapy. For one male resident with obstructive sleep apnea who required BIPAP while sleeping or napping, the care plan and physician orders directed staff to assist with applying and removing the BIPAP mask at bedtime and in the morning, to clean the mask with warm soapy water and air dry as needed, and to clean the reservoir weekly. During observation, his BIPAP mask was found lying unbagged on his nightstand among other personal items, with a greasy substance visible on the mask. The resident reported that staff had removed the mask that morning, placed it on the nightstand, and had not cleaned or bagged it, contrary to the facility’s BIPAP/CPAP administration policy and the infection control expectations described by nursing leadership. Another resident with COPD and multiple fractures required continuous oxygen at 4 L/min via nasal cannula, with a physician order to change the oxygen tubing, nebulizer circuit, and humidifier bottle weekly on the night shift, to label them when changed, and to change and label them every 24 hours as needed when visibly soiled. The resident’s care plan addressed oxygen use and monitoring for respiratory symptoms but did not address the frequency of oxygen tubing changes or labeling. Review of the treatment administration record showed that the oxygen tubing had not been changed on several consecutive days, and during observation the resident was wearing an undated nasal cannula and had an undated oxygen water bottle. The resident stated the tubing had not been changed since admission. Documentation later showed that an LPN changed the tubing and water that same day, but at the time of the initial observation the equipment was not dated as required by the physician order and facility practice. A third resident with obstructive sleep apnea and asthma had a physician order for BIPAP use with specified settings but no orders addressing cleaning frequency or storage of the BIPAP equipment. Her care plan did not address BIPAP use, storage, or cleaning. During observation, her BIPAP mask was found in the top drawer of her nightstand with visible oil buildup, moisture, and a cloudy appearance, and it was not stored in a bag. The resident reported she did not know when the mask was last cleaned and that she used it during naps and at night. Interviews with nursing staff and the DON confirmed that standard practice and protocol required BIPAP masks to be cleaned as needed, bagged when not in use, and oxygen equipment to be changed and dated at least weekly and as needed. These observations and record reviews showed that the facility did not follow its own BIPAP/CPAP administration policy, infection control practices, and physician orders for cleaning, storing, changing, and labeling respiratory equipment for these residents.
Failure to Timely Report Alleged Sexual Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an alleged incident of abuse was reported immediately, and no later than two hours after the allegation was made. During the night shift at approximately 3:00 AM, an LVN observed a male resident in the room of two female residents. The LVN reported finding the male resident feeling around on one female resident’s bed as if trying to find his way back to bed, with the bathroom light on. This male resident had a history of wandering and visual impairment, and had previously wandered into other residents’ rooms. As the LVN and an aide escorted the male resident back to his room, the roommate followed and yelled that her roommate had been molested. The female resident who was the alleged victim was described in her records as an older adult with multiple medical conditions, including hypertension, acute embolism and thrombosis, acute respiratory failure, dysphasia, and reduced mobility. Her care plan reflected a BIMS score indicating moderately impaired cognition and a need for maximal assistance with most ADLs. When the LVN checked on her after the allegation, the resident was sound asleep with covers pulled up to her neck and undisturbed. The LVN did not complete a head-to-toe assessment at that time and only performed a general visual inspection, despite being aware of the allegation made by the roommate. The roommate, who also had moderately impaired cognition but required only setup or clean-up assistance with most ADLs, reported that the male resident had molested her roommate and later demonstrated to the Administrator that the male resident had been rubbing the alleged victim’s thigh and waist area. The LVN acknowledged that she had been trained on abuse and neglect reporting at the facility and knew the protocol, including the requirement to report allegations immediately. However, she did not notify the Administrator or DON of the allegation during the night shift and stated that it slipped her mind due to the busy shift and because she did not personally believe abuse had occurred based on her observations. She wrote the incident on a notepad but did not escalate it. The Administrator first learned of the allegation from the roommate around 11:00 AM, several hours after the alleged incident and the roommate’s initial statement to staff. The facility’s abuse policies required staff to report any suspected abuse to the Executive Director or DON and required covered individuals to immediately notify the Executive Director once they formed a reasonable suspicion that a crime had been committed, with subsequent reporting to law enforcement and the state survey agency within prescribed timeframes. The delay in reporting by the LVN, despite her training and the facility’s written policies, led to the cited deficiency for failure to report an alleged violation involving abuse within the required timeframe.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence or inadequacy of a comprehensive infection prevention and control program, but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt notification and communication regarding an incident that required reporting, as well as the absence of documented follow-up with the appropriate external agencies. The report specifically notes the failure to meet regulatory requirements for reporting and investigation communication, but does not provide further details about the individuals involved or the nature of the incident.
Failure to Thoroughly Investigate Allegation of Exploitation
Penalty
Summary
The facility failed to provide evidence that all alleged violations related to abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one resident. Specifically, a certified nursing assistant (CNA) admitted to asking a resident, who had intact cognition and diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, for $0.50 to buy a soda. The resident reported feeling compelled to give the money and subsequently informed the Administrator. The investigation conducted by the facility was limited to interviews with the resident and the CNA involved, with the CNA admitting to the request and receipt of money. There was no documentation of broader staff education or interviews, nor were other residents interviewed at the time of the incident. The facility's investigation report lacked evidence of comprehensive investigative steps, such as staff and resident interviews beyond those directly involved. The facility's policy required prompt and thorough investigation of all allegations of abuse, neglect, exploitation, or misappropriation, but the documentation did not demonstrate that these procedures were fully followed in this case.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in pressure ulcer management and prevention protocols. The report notes that the facility did not ensure consistent assessment, monitoring, or intervention for residents at risk for or with existing pressure ulcers.
Failure to Provide Pressure Relieving Devices and Repositioning for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to ensure that two residents at risk for pressure ulcers received care consistent with professional standards of practice to prevent the development and worsening of pressure ulcers. Both residents had significant medical histories, including cognitive impairment, immobility, and existing pressure ulcers upon admission. Despite care plans indicating the need for frequent repositioning and the use of pressure-relieving devices, observations revealed that both residents were found lying on their backs without any support or wedges in place, while the wedges intended for their use were observed on their dressers instead of being utilized. For one resident, documentation showed a history of non-compliance with offloading and repositioning, but education was provided and the resident verbalized understanding. The resident's care plan included frequent repositioning and the use of pressure-relieving devices, yet on observation, the resident was not positioned as required. The wound report indicated deterioration of a sacral ulcer, and the care plan emphasized the need for interventions to maintain skin integrity. Staff interviews confirmed that repositioning and the use of wedges were expected practices, but these were not consistently implemented. The second resident, who had multiple stage 2 and stage 4 pressure ulcers and severe cognitive impairment, was also observed lying on her back without support. Her care plan and medical orders required repositioning every two hours and the use of pressure-reducing devices. Staff interviews revealed that repositioning was sometimes delayed or omitted, particularly after bathing or in anticipation of wound care. The facility's policy required repositioning and the use of positioning devices to prevent pressure injuries, but these measures were not consistently followed, as evidenced by the observations and staff statements.
Failure to Maintain Enhanced Barrier Precautions and PPE Availability
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required enhanced barrier precautions due to wounds and skin breakdown. For one resident with multiple pressure ulcers, including stage 2 and stage 4 wounds, there was no enhanced barrier precaution signage or personal protective equipment (PPE) available outside or inside the resident's room following a room transfer. Staff were observed preparing to provide care without donning appropriate PPE until reminded by the wound care nurse, after which the necessary equipment was retrieved and signage was eventually posted. Another resident, who had a history of diabetes, neuropathy, limb amputations, and end-stage renal disease, also required enhanced barrier precautions for a skin opening and monitoring of a shunt/fistula site. However, PPE was not available inside or outside this resident's room as required by facility policy and physician orders. Interviews with staff and the infection preventionist revealed that the signage and PPE were not consistently maintained, particularly after room changes, and that there was confusion or lack of clarity regarding responsibility for ensuring these measures were in place. Record reviews confirmed that both residents had active orders for enhanced barrier precautions and that facility policy required PPE and signage for residents with wounds or indwelling devices. Despite in-service training and established policies, the facility did not consistently provide the necessary supplies or visual cues to support infection control practices, as evidenced by direct observations and staff interviews.
Failure to Implement Abuse and Neglect Reporting Policies
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of one resident with severe cognitive impairment and left-sided paralysis following a stroke. The resident, who required moderate assistance for mobility and had a care plan for regular repositioning and ambulation, was found by a family member to have significant bruising on his left forearm. The family member reported the injury to the DON and an RN, but there was no documentation of progress notes or assessments on the day the bruise was discovered. Despite the facility's policy requiring immediate reporting of injuries of unknown origin to the administrator and state authorities, the injury was not reported as required. Interviews revealed that the DON and nursing staff were notified of the bruise but did not consider it suspicious for abuse, attributing it to the resident's combative behavior during showers. The administrator was not made aware of the injury until much later and only found an email about the incident days after it occurred. The DON and administrator both stated that the injury did not meet the criteria for reporting, and no investigation or timely notification to authorities was completed as outlined in facility policy. The lack of timely assessment, documentation, and reporting of the injury of unknown origin, as well as the failure to follow established abuse and neglect policies, constituted a deficiency. The facility's inaction in this case could have resulted in unaddressed abuse or neglect, as the required procedures for investigation and reporting were not followed for the resident with significant physical and cognitive limitations.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but no later than 2 hours after the allegation was made, as required. Specifically, a resident with severe cognitive impairment and left-sided paralysis was found to have a significant bruise of unknown origin on his left forearm. The bruise was first noticed by a family member, who reported it to the DON and an RN, and followed up with an email, but did not receive a response. The family member also provided a photograph of the bruise, which was described as dark red/purple and extended from the mid-forearm to the elbow. Interviews with staff revealed that the nurse assigned to the resident could not recall the details of the incident, and the RN obtained an x-ray after being notified, which showed no acute fractures. The DON stated that after interviewing staff, it was determined the resident had been combative during showers and could move his left arm, suggesting the bruise may have resulted from this behavior. The DON did not consider the bruise suspicious for abuse and did not report it to the state, believing it did not meet the criteria for reporting. The Administrator confirmed he was not notified of the bruise until much later and, after reviewing the situation, agreed with the DON's assessment that it was not an injury of unknown origin requiring state notification. A review of the facility's policy indicated that all alleged violations, including injuries of unknown source, must be reported immediately to the administrator and appropriate authorities. However, there was no documentation of progress notes or assessments for the resident on the date the bruise was discovered, and the required reporting procedures were not followed. This failure to report the incident as required by policy and regulation constituted the deficiency.
Failure to Provide Adequate Supervision and Safe Transfer Practices
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for two residents. In the first case, a female resident with severe cognitive impairment, a history of falls, and multiple comorbidities including dementia, muscle weakness, and chronic kidney disease, requested to be put to bed. The assigned CNA acknowledged the request but left the room to obtain a mechanical lift and assistance. Due to a miscommunication regarding staff assignments, the resident was left unattended for an extended period. The resident attempted to self-transfer from her wheelchair to the bed, resulting in an unwitnessed fall. She was later found on the floor with a hematoma and two small lacerations on her head and was subsequently transferred to the hospital for evaluation. Interviews with staff revealed confusion over which CNA was responsible for the resident at the time of the incident. The CNA initially assigned to the resident believed she had been reassigned, while the other CNA was unaware of the resident's request to be put to bed. Neither CNA ensured the resident's request was fulfilled or communicated the need for assistance, leading to the resident being left unsupervised. Video footage and interviews confirmed the resident remained on the floor for approximately 23 minutes before staff responded. In the second case, a male resident with severe cognitive impairment, left-sided weakness following a stroke, and total dependence for transfers was transferred using a mechanical lift by a single CNA on two separate occasions. Facility policy and the resident's care plan required two staff members for mechanical lift transfers. Video footage confirmed that both a regular CNA and an agency CNA performed single-person mechanical lift transfers. Interviews with staff and the DON confirmed that this practice was not in accordance with facility policy and posed a safety risk to the resident.
Failure to Document Bruise and Incident in Resident's Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when a significant bruise was discovered on the resident's left forearm. The bruise was first noticed by a family member, who reported it to the DON and an RN. Despite this notification, there was no documentation in the resident's electronic health record (EHR) regarding the bruise, no progress notes, and no assessment completed on the date the bruise was identified. The family member also followed up with an email to the DON, but did not receive a response, and a photograph of the bruise was taken the following day. The resident involved was a male with a history of muscle weakness, dysphagia, osteoarthritis, vascular dementia, and hemiplegia following a stroke, resulting in severe cognitive impairment and left-sided paralysis. The care plan indicated the need for regular repositioning and ambulation assistance. Despite these vulnerabilities, the clinical record did not reflect the presence of the bruise, the incident, or any related assessments or notifications, even though x-rays were ordered and completed, showing no acute fractures or dislocations. Interviews with staff confirmed that the nurse assigned to the resident failed to document the bruise, complete an incident report, or record notifications to the family and physician. The DON acknowledged that her expectations for documentation were not met, and the administrator confirmed that there was no documentation regarding the bruise in the resident's chart. The facility's own policy required documentation of any change in condition, including skin injuries, but this was not followed in this instance.
Failure to Ensure Post-Dialysis Care
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate post-dialysis care, consistent with professional standards and the resident's care plan. The resident, a male with end-stage renal disease and severely impaired cognition, was admitted to the facility and required hemodialysis. The care plan specified that the resident should have no signs of complications from dialysis, and the facility was responsible for sending and obtaining completed dialysis communication sheets from the dialysis center. The facility did not complete post-dialysis assessments for the resident, as evidenced by missing documentation of post-dialysis vital signs and incomplete dialysis communication forms. The resident's electronic health records lacked nursing documentation regarding post-dialysis vital signs, and several dialysis communication forms were missing for multiple dates across August, September, and October. Interviews with staff revealed that they were aware of the requirement to complete these forms and monitor the resident's dialysis access site, but the forms were not consistently filled out or collected. The Director of Nursing and other staff acknowledged the importance of these forms for monitoring vital signs and ensuring communication between the dialysis center and the facility. Despite training sessions conducted on the dialysis communication form, the facility failed to ensure that the necessary post-dialysis monitoring and documentation were consistently performed, potentially placing the resident at risk of complications such as low blood pressure, infection, and bleeding.
Deficiencies in Medication Management and Reconciliation
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by several deficiencies in medication management across multiple medication carts and storage areas. Specifically, insulin pens on Hall E and Hall F medication carts were found to be opened and used without being labeled with opening dates. This oversight was acknowledged by RN N, who admitted that it was the responsibility of all nurses to date insulin upon opening to ensure its efficacy within the 28-day usage period. LVN K also confirmed that it was her duty to check the medication carts for proper labeling, but she had not done so since the previous day. Additionally, expired medications were discovered on the Hall A and Hall D medication carts, including calcium, sodium carbonate, and nitroglycerin, all past their expiration dates. LVN D admitted to not checking the carts for expired medications, which was part of her responsibilities. RN H, who was also responsible for checking these carts, acknowledged missing the expired medications during her last check. The Director of Nursing (DON) confirmed that it was her responsibility to oversee the removal of expired medications and that her managers were delegated to check the carts, but the last check was not thorough enough. Furthermore, a discrepancy was found in the reconciliation of a resident's morphine solution after the resident's death. The narcotic log indicated 20 ml remaining, while the actual bottle contained only 18 ml. The DON admitted to not verifying the narcotic count upon receiving it for destruction, relying instead on the nurse manager's signature. RN H, who cleared the carts of narcotics, also failed to confirm the count accurately. This discrepancy was reported to the police, and the facility began an investigation into the matter.
Failure to Ensure Resident Privacy During IV Medication Administration
Penalty
Summary
The facility failed to respect a resident's right to personal privacy during medical treatment. Specifically, RN A did not provide full privacy for a resident during intravenous medication administration. The resident, a cognitively intact male with a BIMS score of 15, was receiving IV medications related to a skin infection in the groin area. During the procedure, RN A did not close the door or pull the privacy curtain, leaving the resident exposed to anyone passing by. RN A acknowledged her failure to provide privacy, attributing it to nervousness due to the presence of surveyors. The Director of Nursing (DON) confirmed that staff are expected to ensure privacy by closing doors, blinds, and curtains, and covering residents during care. The facility's Resident Rights policy emphasizes the right to personal privacy, which includes medical treatment and personal care, although it does not require a private room for each resident.
Failure to Label IV Medication Bags
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, as observed during a survey. Specifically, the IV medication bags for a resident were not labeled with the date, time, and initials of the administering nurse, which is a requirement to ensure proper medication administration. This oversight was noted during multiple observations, where the resident's IV bags were found unlabeled, potentially leading to medication errors such as missed doses or overdoses. Interviews with nursing staff revealed that the failure to label the IV bags was due to oversight and time constraints, despite the staff being aware of the labeling requirements. The Director of Nursing (DON) confirmed that staff were expected to label IV bags and tubing to prevent medication errors and infections. The facility had conducted training on IV administration, emphasizing the importance of labeling, but the practice was not consistently followed, as evidenced by the observations and staff interviews.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA E, who did not adhere to the required personal protective equipment (PPE) protocols when entering the room of a COVID-positive resident. On the observed date, CNA E entered the room of a resident who was under contact and droplet precautions without wearing an N95 mask or eye protection, despite the clear signage and availability of PPE outside the resident's door. This oversight occurred while CNA E was assisting with housekeeping duties, and she admitted to being unaware of the resident's isolation status. The resident in question, a female with severe cognitive impairment, was admitted to the facility with a displaced fracture and other health issues. Her care plan included enhanced barrier precautions due to surgical incisions, and she was under specific COVID-19 precautions as per physician orders. The facility had clear protocols in place, including signs indicating the necessary PPE for staff entering the room, which CNA E failed to follow. Interviews with facility staff, including the Administrator, DON, and Infection Preventionist, confirmed that the expectation was for all staff to don appropriate PPE before entering rooms of residents with COVID-19. The facility had conducted an in-service training on infection control just two days prior to the incident, which CNA E did not attend. The facility's policy on PPE usage for SARS-COV-2 was also reviewed, highlighting the requirement for respirators and eye protection when caring for COVID-19 positive residents.
Invalid DNR Order Due to Improper Dating
Penalty
Summary
The facility failed to ensure the validity of a resident's Out-of-Hospital Do Not Resuscitate (OOHDNR) order, which was not properly dated by both the resident and the physician at the time of signing. This discrepancy rendered the document invalid, potentially placing the resident at risk of having their end-of-life wishes dishonored. The resident, who was an elderly female with moderate cognitive impairment and multiple diagnoses including Non-Alzheimer's Dementia and Schizophrenia, had conflicting information regarding her code status in her care plan and face sheet. The issue was identified during a review of the resident's records, which showed that the care plan indicated a Full Code status, while the face sheet and order summary reported a DNR status. The Social Worker and MDS Coordinator both acknowledged the inconsistency and the invalidity of the DNR due to the mismatched dates of signatures. The Social Worker noted that the nurses were responsible for updating the system to reflect the resident's code status, and the failure to do so could result in the resident's choices not being honored in critical situations. The Director of Nursing (DON) and the Administrator were informed of the discrepancy, and both confirmed that the DNR was invalid because it was not signed on the same date by all parties. The DON noted that the form appeared to have been altered, with someone other than the resident possibly printing the resident's name and date. The facility's policy on advance directives emphasized the residents' right to self-determination regarding their medical care, highlighting the importance of accurate and up-to-date documentation.
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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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