Marine Creek Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 3600 Angle Ave, Fort Worth, Texas 76106
- CMS Provider Number
- 675779
- Inspections on file
- 58
- Latest survey
- January 12, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Marine Creek Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident under 22 years old with severe TBI, ventilator dependence, total ADL dependence, and multiple complex medical needs did not receive required permanency planning services. State-contracted permanency planning staff repeatedly emailed and called the facility’s SW requesting records and providing official guidance and Form 2437, but the SW, unfamiliar with permanency planning, questioned the legitimacy of the request, did not document or escalate it, and did not respond. The CD believed permanency planning applied only to PASRR-positive residents and took no action after a negative PASRR evaluation, and the facility had no policy on permanency planning. As a result, the facility failed to provide medically related social services necessary to support permanency planning for this under-22 resident.
Two assisted lifting devices were found improperly secured in facility hallways, with one left free rolling and another locked by only one wheel, despite staff training on proper procedures. Residents were observed walking past these unsecured devices, and both staff and the DON acknowledged the risk of accidents from improper storage.
Two residents with behavioral and psychiatric histories engaged in escalating verbal and physical altercations, culminating in one resident being punched in the face by the other. Staff were aware of prior conflicts and complaints but did not separate the residents or implement effective interventions, resulting in physical injury and a failure to protect residents from abuse as required by facility policy.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Feeding tubes were utilized for a resident without documented medical justification or resident consent, and appropriate care for a resident with a feeding tube was not provided.
The facility failed to ensure that emergency crash carts were properly stocked and checked daily, resulting in a missing Ambu bag on one cart and incomplete inventory checks on another. Staff interviews revealed confusion over responsibility for maintaining the carts, and the DON was not aware of the facility's policy regarding daily checks. These deficiencies could delay emergency care for residents in need of basic life support.
A resident with multiple complex medical conditions, including COPD and on hospice care, was placed on a non-rebreather mask for high-flow oxygen without a physician order and with incorrect oxygen flow rates for several days. Staff were unclear about the need for specific orders and proper mask settings, and the resident's care plan was not updated to reflect this change in respiratory therapy.
A nurse without proper training in non-rebreather mask use administered oxygen therapy at an incorrect flow rate to a resident with COPD and other complex conditions. The resident's care plan did not include non-rebreather use, and there was a lack of appropriate physician orders and documentation. Interviews confirmed that staff were unfamiliar with correct procedures, and the facility's policy on oxygen administration was not followed.
A facility failed to label a resident's enteral nutrition formula and water bags with the date and time, as required. This oversight was observed during a survey, where the resident, who had a history of acute respiratory failure and required enteral feeding, was at risk of malnutrition and dehydration. Staff interviews confirmed the labeling should have been done, but the facility's policy did not specify this requirement.
A resident's right to retain personal possessions was violated when the Administrator took away her cell phone after she repeatedly called 911 due to breathing difficulties. The resident, who was ventilator-dependent, was unable to speak to the 911 operator. The phone was returned within 10 minutes after the family was informed and communicated with the resident to stop the calls.
A resident with dementia and schizophrenia was verbally abused by a CNA who attempted to force her to bed, witnessed by family via a video camera. The resident's care plan, which included interventions for behavior management, was not followed, leading to the escalation of the situation. The incident was not reported by the assisting LVN, contrary to the facility's abuse policy.
A facility failed to maintain a safe environment for a legally blind resident requiring supervision with bed mobility. The resident's bed was lopsided, causing discomfort and potential fall risk. Despite the resident's report to the Maintenance Director, the issue persisted. The DON and Administrator did not perceive a risk, and no accident prevention policy was provided.
The facility failed to maintain an effective pest control program, leading to the presence of flies and roaches. Residents reported sightings of roaches in their rooms, and flies were observed on a mattress. The Maintenance Director confirmed weekly pest control visits, but issues persisted. Pest control records showed multiple roach sightings, and the DON and Administrator were unaware of the problem's extent.
The facility failed to provide proper respiratory care for two residents, as their nasal cannulas were not bagged for sanitation and their oxygen concentrators were contaminated with debris. Despite being cognitively intact, the residents' care plans were not followed, leading to potential risks of respiratory infections. Interviews revealed inconsistencies in staff responsibilities for maintaining oxygen equipment, and the facility's policy did not address proper storage of tubing.
A resident with severe cognitive impairment was left exposed and naked when an LVN and a contractor entered the room without closing the privacy curtain. The LVN, unfamiliar with the resident's care needs, focused on locating an oxygen concentrator, leading to a breach of privacy. The facility's policy emphasized dignity and privacy, but the incident highlighted a failure to uphold these standards.
A resident with Muscular Dystrophy and quadriplegia did not receive scheduled showers, as required for her care, due to staff not offering them consistently. Despite being cognitively intact and dependent on staff for bathing, the resident reported long periods without showers, which was confirmed by facility records. Staff interviews revealed a lack of documentation for shower refusals, and the facility's policy on bathing was not followed, impacting the resident's hygiene and well-being.
A facility failed to document physician orders for ventilator settings for a resident with complex medical needs, including chronic respiratory failure and ALS. Despite the resident's dependence on a mechanical ventilator, the necessary orders were not recorded from the time of readmission. Staff interviews revealed that the ventilator settings were known and monitored, but the admitting nurse did not document the orders. The facility could not provide a policy for physician orders, indicating a gap in adherence to existing policies.
A long-term care facility failed to maintain an effective infection control program, as observed by surveyors. An LVN did not disinfect a blood sugar monitoring device between uses on multiple residents and failed to perform hand hygiene. Additionally, an RN did not adhere to enhanced barrier precautions when administering G-tube medication, neglecting to wear PPE and perform hand hygiene. Staff interviews revealed a lack of awareness and training on infection control procedures.
A fly infestation in the dining room affected three residents, including a cognitively intact male with a history of stroke, a male with severe cognitive impairment, and a female with moderate cognitive impairment. Despite regular pest control treatments, flies were observed on residents and tables, impacting their dining experience.
The facility failed to ensure call lights were within reach for two residents, both with moderate cognitive impairments and fall risks. One resident's call light was found under the fitted sheet, while another's was on the floor. Staff interviews revealed a lack of adherence to care plans requiring call light accessibility, and the facility lacked a policy to ensure compliance.
A facility failed to ensure privacy and confidentiality for residents in a shared room by not obtaining proper consents for an AEM camera. A resident with severe cognitive impairment had a camera placed in their room without consent from the roommate, leading to potential exposure of personal information. Staff interviews revealed a lack of clear policy and responsibility for managing AEM consents.
A resident with complex medical needs did not receive proper G-tube care, as the facility failed to change the water bag and enteral administration set with formula changes. This oversight, observed during a survey, was due to inadequate adherence to procedures and insufficient staff training, increasing the risk of infection.
A resident with complex medical conditions was admitted with a PICC line, but the facility failed to obtain necessary orders or perform required dressing changes, placing the resident at risk for infection. Staff interviews revealed a lack of clarity and action regarding PICC line management, and the facility did not provide a policy for PICC/IV dressing changes, contrary to CDC guidelines.
The facility failed to secure medication and respiratory treatment carts, leaving them unlocked and unattended in hallways. Staff interviews confirmed that the carts should be locked when not in use, as per facility policy, to prevent unauthorized access to medications.
A facility failed to notify the State LTC Ombudsman of a resident's transfer to the hospital, as required by policy. The resident, with chronic respiratory issues, was transferred after reporting shortness of breath and chest pain. Interviews revealed confusion among staff about who was responsible for sending discharge notices, leading to the oversight. The facility's policies mandate notification to the resident, their representative, and the ombudsman, which was not followed in this case.
A resident with chronic respiratory issues and a tracheostomy was transferred to a hospital without receiving written information about the facility's bed-hold policy. Upon readiness to return, the facility had no available bed, as confirmed by staff interviews. The facility's admission packet required bed-hold information to be provided, but this was not done.
A resident with a tracheostomy experienced severe health issues due to the facility's failure to adhere to recommended tracheostomy tube cuff pressure. The resident's cuff was chronically overinflated, leading to vertebral remodeling and swallowing difficulties, which likely caused starvation ketoacidosis. Despite staff awareness of the resident's requests for more air, proper procedures were not followed, and the issue went unaddressed until the resident was hospitalized.
A facility failed to provide adequate respiratory care for residents requiring oxygen therapy and CPAP use. Observations revealed undated and unbagged oxygen tubing and CPAP masks, with staff interviews indicating lapses in equipment management practices. These deficiencies affected residents with conditions such as COPD and acute respiratory failure, highlighting inconsistencies in following facility policies for infection prevention.
A resident with severe cognitive impairment and multiple medical conditions exhibited behaviors such as not using the call light and removing his CPAP mask, which were not reflected in his care plan. Despite staff awareness of these behaviors, the care plan was not updated, potentially risking inadequate care. The facility's policy requires person-centered care plans, but a communication gap led to this oversight.
A resident's call light was found on the floor and not within reach, despite the care plan requiring it to be accessible. The resident, who was severely cognitively impaired and required maximal assistance, was agitated and stated that no one had come to help him. Staff were unaware of the call light's location, and the facility lacked a call light policy.
A resident with a history of dementia, diabetes, falls, and muscle weakness was found on the floor by a student nurse aide during the evening shift. The incident was not reported to the charge nurse until several hours later, resulting in a delay in medical assessment and care. The resident sustained significant bruising and injury to the right side of the face and head. The delay highlighted gaps in staff training and awareness, as well as confusion and miscommunication regarding incident reporting and response procedures.
A facility did not adhere to its written policies and procedures designed to prevent abuse, neglect, and exploitation of residents. An incident involving a resident with dementia, diabetes, falls, and muscle weakness highlighted this deficiency. A Student Nurse Aide found the resident on the floor with significant bruising and head injury but failed to report the incident to the charge nurse. This resulted in a delay in the resident receiving necessary treatment, including neurological checks and physician notification. The facility's policies emphasize timely reporting in such cases, but staff training and awareness of protocols were insufficient.
A resident with severe cognitive impairment and a history of wandering behaviors exited into an enclosed courtyard during a storm and remained outside for approximately 3 hours. The door to the courtyard, which required a code to open, was left unlocked or unsupervised when its locking mechanism lost power. The resident's care plan included interventions to prevent elopement, but these measures were not effectively implemented. The resident was found lying on the ground in the courtyard, prompting an investigation into the incident.
A facility failed to report a resident's fall and subsequent injuries in a timely manner. A student nurse aide found the resident on the floor but did not notify the charge nurse, resulting in a delay in treatment. The administrator also failed to report the incident to state authorities.
Failure to Provide Required Permanency Planning Services for a Resident Under 22
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services, specifically permanency planning services, to a resident under the age of 22 as required by Texas regulations. The resident was a young adult with a history of diffuse traumatic brain injury with loss of consciousness, ventilator dependence via tracheostomy, severe mobility limitations, GERD, generalized anxiety disorder, and depression. Her MDS reflected severe cognitive impairment, no speech, dependence on staff for all ADLs with two-person assist, risk for dehydration and shortness of breath, need for parenteral/IV feeding and feeding tube, risk for pressure ulcers, and multiple special treatments including oxygen, suctioning, tracheostomy care, invasive mechanical ventilation, and IV access. The care plan and MD orders documented extensive medical and nursing needs, including anticoagulant therapy, seizure disorder, bowel incontinence, enhanced barrier precautions, feeding tube management, and tracheostomy care. Despite the resident’s age and the Texas requirement that permanency planning be completed every six months for individuals under 22 residing in nursing facilities, the facility did not ensure that permanency planning was initiated or supported. The Permanency Planning Contractor (PPC) sent emails to the facility social worker (SW) on multiple dates with a provider letter explaining permanency planning requirements, a blank Form 2437 (Notification of Nursing Facility Admission of Person Under Age 22), and information that permanency planning is mandated under Texas Administrative Code. The PPC reported requesting records on several occasions and informing the SW that records were required within three days. The PPC also stated that a negative PASRR result would not prevent permanency planning services. However, the facility’s Clinical Director (CD) stated that permanency plans were only completed for PASRR-positive residents under age 22 and that, because the resident’s PASRR evaluation was negative, no further action was taken. The SW reported being unfamiliar with the term “permanency planning” and stated that when contacted by the PPC for the resident’s care files and related documents, she questioned the legitimacy of the request, was concerned about HIPAA and confidentiality, and did not feel comfortable providing information. She indicated that the PPC could not provide sufficient information about the resident’s relation and purpose of the request, and she did not document the contact, did not forward the emails to the DON or administrator, and did not contact HHSC, the PPC, or a PPC superior to verify the request. The SW initially denied receiving emails from the PPC, and it was only after the surveyor requested supporting documentation that the SW produced the email correspondence. Interviews also revealed that the DON and CD could not provide a facility policy on permanency planning, and both reported that no such policy existed. As a result of these actions and inactions—misunderstanding of PASRR’s role, failure to recognize and act on permanency planning requirements for a resident under 22, failure to respond to PPC requests, and lack of policy guidance—the facility did not provide the required medically related social services related to permanency planning for this resident. The resident remained non-interviewable during survey observations due to her traumatic brain injury, but she was observed awake in bed, ventilator-dependent, with clean equipment and environment, and able to visually track the surveyor. The record review confirmed that the resident had been in the facility for several months, and the SW’s own note documented initial contact from an individual stating the resident had been flagged by the state for permanency placement assistance due to age. The SW’s note also reflected her discomfort with the call, her belief that the caller’s identification as a state representative was questionable, and her decision not to proceed without consulting the family or administration, yet she did not follow through with leadership or regulatory contacts. The combination of the facility’s lack of a permanency planning policy, the SW’s lack of knowledge and failure to act on multiple PPC contacts, and the CD’s reliance on PASRR status instead of permanency planning regulations led directly to the failure to assist this under-22 resident in obtaining permanency planning resources and services as required. Additionally, the DON reported that she had completed the initial PASRR at admission, determined the resident was positive, and submitted the 2401 form to HHSC, after which a QIDP evaluation concluded the resident did not qualify for PASRR services. The DON stated that the family was informed of these PASRR results and agreed to services for the resident, and that the SW was assigned to contact the provider about the records request. However, the SW did not complete this assignment and did not engage with the PPC to move forward with permanency planning. The surveyor’s review of the SW’s personnel file showed that she had been hired earlier in the year at a sister facility and transferred to the current facility shortly before the PPC contacts, and there was no evidence that she had prior training on permanency planning before the in-service that occurred after the PPC’s initial outreach. The absence of a facility policy, combined with the SW’s inaction and the CD’s misunderstanding of regulatory triggers, resulted in the resident not receiving the medically related social services necessary to support permanency planning.
Failure to Secure Assisted Lifting Devices Creates Accident Hazards
Penalty
Summary
The facility failed to ensure that the resident environment remained free of accident hazards in two of four hallways reviewed. Specifically, two of four assisted lifting devices were not properly secured while being stored in the hallways. Observations showed that one hydraulic assisted lifting device in the 200 hallway was left free rolling with unsecured wheels, and another device in the 400 hallway had only one wheel locked, allowing it to spin freely. Several residents were observed ambulating past these unsecured devices. Record review indicated that the facility's policy and user manual lacked clear instructions on proper storage and locking of these devices when not in use. Interviews with staff and the DON confirmed that training had been provided on locking all wheels of assisted lifting devices when not in use, and staff acknowledged the risk of accidents if devices were not properly secured. Despite this training, the devices were found unsecured or improperly secured during the survey, indicating a failure to consistently implement safety procedures for storing assisted lifting devices in resident areas.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in one resident being physically assaulted by another. The incident involved a resident with a history of hemiplegia, hemiparesis, cognitive communication deficit, and mood disorder, who was punched in the face by his roommate, a resident with diagnoses including bipolar disorder with psychotic features and intermittent explosive disorder. Prior to the altercation, there were documented verbal disagreements and escalating tensions between the two residents, including complaints about noise and mutual accusations of disruptive behavior. Staff were aware of at least one verbal disagreement the day before the physical altercation, but the residents were not separated or further interventions implemented to prevent escalation. On the night of the incident, the two residents engaged in a heated exchange that escalated to physical violence. One resident reported being struck in the mouth and chest, and sustaining a skin tear and scratches. Both residents provided accounts of the altercation, with each blaming the other for initiating the physical aggression. Staff interviews confirmed that the altercation was preceded by loud arguments and that a nurse intervened by removing one resident from the room, but the other resident followed and delivered a punch in the hallway. The facility's Director of Nursing and Assistant Director of Nursing acknowledged that there was prior knowledge of the residents' incompatibility and that the incident could have been prevented if staff had been informed of the escalating conflict. The facility's abuse and neglect policy requires prompt recognition, reporting, and investigation of abuse, including resident-to-resident altercations. However, the report indicates that staff did not act on early warning signs or previous behavioral history, such as the new resident's involvement in a prior altercation at another facility and the ongoing complaints from the other resident about his roommate. The lack of timely intervention and failure to separate the residents after initial signs of conflict directly contributed to the physical abuse incident.
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 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.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the procedure. Additionally, appropriate care and services for a resident with a feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
Failure to Maintain Emergency Crash Cart Supplies and Daily Checks
Penalty
Summary
The facility failed to ensure that basic life support equipment and procedures were consistently available and followed prior to the arrival of emergency medical personnel, as required by physician orders and residents’ advance directives. Specifically, Emergency Cart 1 was found to be missing an Ambu bag, a critical device for providing ventilation to residents who are struggling to breathe or have stopped breathing. Staff interviews revealed that the absence of the Ambu bag was justified by the presence of Ambu bags in residents’ rooms and in the central supply closet, but this did not align with facility policy, which required an Ambu bag to be present on the emergency cart itself. Additionally, the facility did not maintain proper daily inventory checks on Emergency Cart 2. Review of the emergency cart’s daily check-off logs showed multiple days where no inventory check was completed. Staff interviews indicated confusion and lack of clarity regarding responsibility for checking the emergency carts, with some nurses believing it was a shared responsibility and others stating it was assigned to specific staff. The facility’s policy required daily checks and immediate restocking after use, but this was not consistently followed. Further interviews with nursing and administrative staff revealed inconsistent understanding of the procedures for maintaining emergency carts. While some staff stated that night shift nurses were responsible for daily checks, others believed central supply was responsible for monthly checks and restocking. The Director of Nursing was not aware of the specific policy regarding daily checks and could not articulate the associated risks. The lack of clear assignment and adherence to policy resulted in emergency carts not being reliably stocked and ready for use, potentially delaying emergency care.
Failure to Obtain and Follow Physician Orders for Non-Rebreather Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care, specifically the use of a non-rebreather mask for high-flow oxygen therapy, received care consistent with professional standards, physician orders, and the resident's care plan. The resident, an elderly female with diagnoses including dementia, myxedema coma, heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and COPD, was on hospice care and dependent on staff for all activities of daily living. Her care plan and physician orders specified oxygen therapy via nasal cannula at 2-4 liters per minute, but did not include orders for non-rebreather mask use or high-flow oxygen therapy. On several occasions, nursing staff and hospice personnel initiated the use of a non-rebreather mask for the resident when she experienced shortness of breath and low oxygen saturation. However, there was no documented physician order for this intervention, and the mask was set at oxygen flow rates below the recommended minimum for non-rebreather use (less than 10 liters per minute) for an extended period. Staff interviews revealed confusion and lack of familiarity with the appropriate use and settings for non-rebreather masks, as well as uncertainty about the process for obtaining and documenting physician orders for changes in oxygen delivery methods. The non-rebreather mask remained in use for several days without proper orders or adjustment to the correct oxygen flow rate, and the care plan was not updated to reflect this change in therapy. Documentation and interviews further indicated that communication between facility staff, hospice nurses, and respiratory therapists was inconsistent. Some staff assumed that existing oxygen orders covered the use of a non-rebreather mask, while others believed that emergency use did not require a new order. The Director of Nursing and other staff acknowledged that physician orders are required for all oxygen delivery methods, but this was not consistently followed. The lack of specific orders and failure to follow professional standards for respiratory care placed the resident at risk for inappropriate oxygen therapy.
Failure to Ensure Nurse Competency in Oxygen Therapy Administration
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skill sets to care for residents as identified through assessments and care plans. Specifically, a nurse (RN A) was not trained in the use of a non-rebreather mask for oxygen therapy and was unfamiliar with the required oxygen flow parameters and when to discontinue its use. This resulted in a resident with multiple complex medical conditions, including COPD, being placed on a non-rebreather mask at an incorrect oxygen flow rate without appropriate physician orders or documentation in the care plan. The resident in question was an elderly female with diagnoses including dementia, myxedema coma, heart failure, atrial fibrillation, acute respiratory failure with hypoxia, and COPD. She was dependent on staff for all activities of daily living and required oxygen therapy as part of her care. The care plan specified oxygen via nasal cannula at 2-4 L/min but did not include the use of a non-rebreather mask. Despite this, RN A placed the resident on a non-rebreather mask at 5 L/min following a hospice nurse's suggestion, although the standard for non-rebreather masks is a minimum of 10 L/min. RN A admitted to never having used a non-rebreather before and was not familiar with its proper use. Interviews revealed that the hospice nurse did not provide explicit orders to continue the non-rebreather mask and was unaware it was left on the resident for an extended period. Additionally, a hospice CNA reported finding the resident without oxygen or with an empty oxygen tank on several occasions and had to notify facility staff. The Director of Nursing confirmed that non-rebreather masks should be set at 10-15 L/min and would not expect them to be used at lower rates. The facility's policy required staff to be familiar with oxygen administration methods, but this was not followed in the resident's care.
Failure to Label Enteral Nutrition Bags
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition was provided with the appropriate treatment and services to prevent complications associated with tube feeding. Specifically, the facility did not label the formula and water bag with the date and time they were started, which is a critical step in managing enteral nutrition. This oversight was observed during a survey, where it was noted that the resident's formula and water bag lacked the necessary labeling, potentially placing the resident at risk of malnutrition and dehydration. The resident in question was a male with a history of acute respiratory failure with hypoxia, tracheostomy status, and gastrostomy status, requiring enteral feeding. The facility's policy on enteral nutrition did not specify the requirement for dating and timing the formula and water bags, which contributed to the deficiency. Interviews with staff, including an LVN and the Administrator, confirmed that the labeling should have been done, and the absence of such labeling could lead to the resident receiving incorrect nutrition levels.
Resident's Right to Retain Personal Possessions Violated
Penalty
Summary
The facility failed to ensure that a resident retained the right to use personal possessions, specifically a cell phone, which was taken away by the Administrator. The resident, who was dependent on a ventilator and had a tracheostomy, called 911 several times because she felt she could not breathe. However, she was unable to speak to the 911 operator and would hang up. The local police department contacted the Administrator about the repeated 911 calls, and the Administrator, concerned about the potential for the resident to receive a citation for abuse of the 911 system, took the phone away. The resident's family was informed of the situation, and they communicated with the resident via text to stop calling 911. The phone was returned to the resident within about 10 minutes. The facility's policy on resident rights states that residents have the right to retain and use personal possessions unless it infringes on the rights or health and safety of others. The report does not indicate that the resident's death was related to the removal of the phone.
Failure to Prevent Verbal Abuse of Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a CNA, which was witnessed by the resident's family through a video camera in the resident's room. The incident occurred when the CNA attempted to force the resident to go to bed by grabbing the resident's arm and yelling, causing the resident to become angry. The resident, who has a history of dementia and schizophrenia, was resistant to going to bed and was looking for her purse, a common behavior before bedtime. The resident's care plan indicated that she had behavior problems related to her disease process, including fighting during showers, refusing assistance with ADLs, and refusing to go to bed at night. The care plan included interventions such as offering pleasant diversions, structured activities, and speaking in a calm manner. However, these interventions were not followed, and the CNA's actions escalated the situation, leading to verbal abuse. The incident was not reported by the LVN who assisted the CNA, as they did not perceive it as significant due to the lack of physical injury. The facility's abuse policy requires the reporting and investigation of all incidents of abuse, neglect, or mistreatment, but this protocol was not followed. The failure to report and address the incident promptly could place residents at risk for staff mistreatment.
Failure to Maintain Safe Bed Environment for Resident
Penalty
Summary
The facility failed to maintain a safe environment for a resident, who was legally blind and required supervision with bed mobility. The resident's bed was observed to be lopsided, which the resident reported as uncomfortable and causing sleep disturbances. Despite the resident informing the Maintenance Director about the issue, the bed remained in the same condition later in the day. The Licensed Vocational Nurse (LVN) acknowledged the bed's crooked appearance and recognized the potential risk of the resident falling off the bed. However, the Maintenance Director attributed the lopsided appearance to the resident's sitting position and weight distribution, rather than a defect in the bed frame or mattress. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of concern regarding the unevenness of the bed and headboard, with both stating there was no risk to the resident. The facility did not provide a policy on accident prevention, indicating a gap in their procedures for addressing environmental hazards. This oversight in maintaining the resident's bed and the absence of a formal policy on accident prevention contributed to the deficiency identified by the surveyors.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and roaches within the premises. Observations and interviews revealed that residents had encountered roaches in their rooms, with one resident reporting a roach crawling on her bed and another resident witnessing roaches under the bed. Flies were also observed in a resident's room, particularly on a mattress with a yellowish-brown stain. The Maintenance Director acknowledged the presence of pests and stated that pest control services were conducted weekly, but urgent issues required immediate attention. Despite these measures, residents continued to report sightings of pests, indicating an ineffective pest control program. The facility's pest control records showed multiple reports of roach sightings in various rooms over several months, with specific entries detailing live roaches found during inspections. The Director of Nursing and the Administrator were unaware of the extent of the pest problem, as they had not received complaints or seen pests themselves. The facility's policy on insect and rodent control, dated 2012, was not effectively implemented, as evidenced by the ongoing pest issues and the lack of a comprehensive pest control policy beyond the food service department.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, as observed during a survey. Resident #5's nasal cannula was not bagged for sanitation when not in use, contrary to the facility's policy. Additionally, the resident's oxygen concentrator and filter were found to be contaminated with food crumbs, dust, and a spilled brown liquid. Despite being cognitively intact, Resident #5's care plan noted that she did not replace the nasal cannula in a bag when removing it, and it was sometimes found on the floor. Interviews with staff revealed inconsistencies in the maintenance and cleaning responsibilities for the oxygen equipment. Resident #16 also experienced similar issues with respiratory care. His nasal cannula was observed lying on the floor with the prongs touching the ground, and the oxygen concentrator was found with food crumbs and dust particles. The resident, who was cognitively intact, reported that staff did not bag the nasal cannula and he could not reach it when it fell. The facility's policy required nasal cannulas to be bagged when not in use, but this was not adhered to, leading to potential risks of respiratory infections. Interviews with nursing staff and the Director of Nursing (DON) highlighted a lack of clarity regarding the responsibilities for cleaning and maintaining the oxygen equipment. The facility's policy on oxygen administration did not address the storage of tubing when not in use, contributing to the observed deficiencies. The absence of a documented in-service training on respiratory care further indicated gaps in staff education and adherence to protocols.
Privacy Breach in Resident Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident, identified as Resident #1, who was severely cognitively impaired with a BIMS score of 02 and required maximal assistance with activities of daily living. During an observation via a Ring Camera, it was noted that a Licensed Vocational Nurse (LVN) and a male contractor entered the resident's room without closing the privacy curtain, leaving the resident exposed and naked. The resident's care plan indicated that the family preferred the resident not be clothed due to agitation, but the facility's policy on resident rights emphasized the need for dignity and privacy. The LVN admitted to not being familiar with the resident's treatment and care needs at the time of the incident and acknowledged the oversight in not closing the privacy curtain or covering the resident. The Director of Nursing (DON) did not respond to questions about the privacy breach, and the facility's policy underscored the importance of treating residents with respect and dignity. The incident highlighted a failure to protect the resident's privacy, as the LVN focused on locating an oxygen concentrator for the contractor, inadvertently exposing the resident to potential embarrassment.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADL) to Resident #33, specifically in ensuring regular showers or baths. Resident #33, a cognitively intact individual with a BIMS score of 14, has a primary diagnosis of Muscular Dystrophy and secondary diagnoses including quadriplegia, heart failure, and contractures. The resident is totally dependent on staff for showering, requiring the assistance of two staff members. Despite this, the resident reported not receiving showers for extended periods, including a three-week gap, and stated that staff often did not ask if she wanted a shower on her scheduled days. Interviews with facility staff, including a CNA and an LVN, confirmed that the facility tracks showers in an electronic medical records system and does not maintain paper logs. The staff described a system where residents in odd-numbered rooms are scheduled for showers on specific days, with A beds showered during the morning shift and B beds during the evening shift. However, the records showed that Resident #33 had only been showered twice in the last 30 days, with no documentation of refusals, corroborating the resident's account of inadequate showering. The facility's administrator confirmed that CNAs are responsible for showering residents and that refusals should be documented. The administrator expects staff to offer showers a second time if initially refused and to care plan for residents who repeatedly refuse showers. The facility's policy emphasizes the importance of bathing for hygiene and comfort, yet the lack of adherence to this policy resulted in Resident #33 not receiving the necessary care, potentially affecting her quality of life and self-esteem.
Failure to Document Ventilator Settings for Resident
Penalty
Summary
The facility failed to ensure that physician orders were written for ventilator settings for a resident from the time of their admission to the facility. This oversight was identified during a review of the resident's medical records, which revealed that there were no documented ventilator setting orders from the time the resident was readmitted to the facility. The resident, who was dependent on a mechanical ventilator, had a complex medical history including chronic respiratory failure, sepsis, pneumonia, and ALS. Despite the critical nature of the resident's condition, the necessary physician orders for ventilator settings were not documented, which could potentially compromise patient safety. Interviews with facility staff, including a respiratory therapist (RT) and the Director of Nursing (DON), revealed that the ventilator settings were known to the RT and were documented on the resident's flow sheet in the electronic medical record (EMR). However, the RT and DON both acknowledged that the admitting nurse should have placed the order for the ventilator settings upon the resident's return from the hospital. The RT stated that there was no risk to the resident because the ventilator settings were monitored and adjusted as needed based on the resident's vitals and oxygenation. The facility's administration, including the Administrator (ADM), expressed an expectation that orders should drive care and that nursing and respiratory staff should obtain the necessary orders for care. Despite this expectation, the facility was unable to provide a policy for physician orders when requested. The existing policy on medication orders emphasized the need for a current list of orders to be maintained in the clinical record of each resident, highlighting a gap in adherence to this policy in the case of the resident's ventilator settings.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. Specifically, the facility did not ensure that a Licensed Vocational Nurse (LVN) disinfected a blood sugar monitoring device between uses on multiple residents. The LVN also failed to perform hand hygiene after removing gloves and handling the contaminated device. This oversight was observed during blood sugar checks for several residents, including those with diabetes and other serious health conditions. Additionally, the facility did not ensure that a Registered Nurse (RN) adhered to enhanced barrier precautions when administering G-tube medication to a resident. The RN did not wear the required personal protective equipment (PPE) and failed to perform hand hygiene before donning gloves. This resident had multiple health issues, including cerebral palsy and a history of urinary tract infections, which necessitated strict infection control measures. Interviews with staff revealed a lack of awareness and training regarding infection control procedures, including the sanitization of shared equipment and the use of PPE. The Assistant Director of Nursing (ADON) acknowledged the need for in-service training on these protocols, while the Director of Nursing (DON) and Administrator expressed expectations for staff compliance with infection control policies. The facility's policy emphasized the importance of hand hygiene as a primary means of preventing infection transmission, yet these practices were not consistently followed.
Fly Infestation in Dining Room Affects Residents
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a fly infestation in the dining room, affecting three residents. Resident #66, a cognitively intact male with a history of stroke and other health issues, was observed with flies on his body while sitting in the dining room. He expressed discomfort and dissatisfaction with the presence of flies, which had been a problem for the past week. Resident #42, a male with severe cognitive impairment and multiple health conditions, was also affected by the fly infestation in the dining room. He expressed feeling like he was in a trash dumpster due to the flies. Observations noted that flies were present on 80% of the tables in the dining room, indicating a widespread issue. Resident #103, a female with moderate cognitive impairment and other health issues, was observed shooing flies away from her food while eating in the dining room. Interviews with staff revealed that the facility had a pest control program in place, with regular visits from a pest control company. However, the surrounding environment, including a barn, creek, and wooded area, posed challenges in controlling the fly population. The facility's pest control logs documented regular treatments for various pests, including flies, but the issue persisted, impacting the residents' dining experience.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents, Resident #17 and Resident #114, were within their reach, which is a necessary accommodation for their needs. Resident #17, a female with a history of Covid-19, schizoaffective disorder, dementia, and multiple fractures, was found with her call light tucked underneath her fitted sheet, making it inaccessible. This resident had a recent fall resulting in multiple injuries, including fractures and a lip laceration, which occurred when she attempted to go to the restroom without assistance. The care plan for Resident #17 specifically required that her call light be kept within reach due to her fall risk. Similarly, Resident #114, a male with a history of cerebral infarction, dementia, and other conditions, was observed with his call light on the floor, out of his reach. This resident also required assistance with daily activities and had a care plan that mandated the call light be accessible to prevent falls and ensure he could request help when needed. Both residents were unable to locate their call lights when asked, indicating a failure in the facility's responsibility to accommodate their needs. Interviews with staff, including an LVN and a CNA, revealed that the call lights were not placed back within reach after linens were changed or other room activities were conducted. The facility's Administrator and DON acknowledged that it was the responsibility of nursing staff and other personnel to ensure call lights were accessible to residents. However, there was no existing policy in place to guide staff on maintaining call light accessibility, contributing to the oversight and potential risk to resident safety.
Privacy Breach Due to Unauthorized AEM in Shared Room
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical information, specifically for a resident who shared a room with another resident. An AEM camera was observed in the shared room, capturing most of the room and the bed area of the roommate. The facility did not have signed consents from the roommates or their responsible parties in the active section of their electronic health records, which could lead to exposure of personal and medical information. Resident #18, a Hispanic male with a primary language of Spanish, was admitted to the facility with multiple diagnoses, including hemiplegia, alcohol-induced dementia, and type 2 diabetes. The resident had a BIMS score indicating severe cognitive impairment and required significant assistance with daily activities. Despite these conditions, there was no assessment for the ability to consent or any consent for AEM documented in the resident's records. Interviews with staff and the resident's responsible party revealed that the camera was placed without notifying the facility, and the responsible party was unaware of the need for consent from the roommate. The facility's staff indicated that if a roommate did not consent to AEM, they would attempt to move the resident to another room. However, there was no clear policy on audio recordings, and the facility lacked a designated person responsible for managing AEM consents.
Failure to Change G-Tube Tubing and Water Bag
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via a gastrostomy tube (G-tube) received appropriate treatment and services according to professional standards. Specifically, the facility did not change the G-tube water and enteral administration set when the resident's formula was changed on two occasions. This oversight was observed during a survey, where it was noted that the water bag was not changed for several days, and the tubing was not replaced with the formula change, which could increase the risk of infection. The resident involved was a male with multiple complex medical conditions, including acute respiratory failure, bacterial infection, cerebral palsy, and dependence on respirator ventilation. He was completely dependent on staff for all activities of daily living and had a G-tube for nutrition. Despite these needs, the facility's care plan and order summary did not specify the requirement to change the tubing with each enteral feeding setup, nor did it reflect the need to change the enteral feed syringe every 24 hours. Interviews with nursing staff revealed a lack of adherence to proper procedures and a gap in training. One nurse admitted to not changing the tubing and water bag since a specific date, while another nurse acknowledged forgetting to change the tubing when adding a new formula bag. The Director of Nursing confirmed that the facility's policy required the tubing to be changed with every feeding change, but there was no clear monitoring process to ensure compliance. The facility's policies on enteral nutrition and infection control did not adequately address the replacement of tubing or dating of bags, contributing to the deficiency.
Failure to Manage PICC Line for Resident
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, specifically regarding the management of a Peripherally Inserted Central Catheter (PICC) line. The resident, a male with multiple complex medical conditions including hypotension, pneumonia, and dependence on respirator ventilation, was admitted with a PICC line. However, since admission, there were no orders to manage, access, flush, or perform dressing changes on the PICC line, which is crucial for preventing infection. Observations and interviews revealed that the nursing staff, including Licensed Vocational Nurses (LVNs) and Registered Nurses (RNs), were aware of the PICC line but failed to obtain necessary orders or perform required dressing changes. The Assistant Director of Nursing (ADON) and LVNs acknowledged the need for dressing changes and monitoring but did not take action to ensure these were completed. The PICC line dressing was not changed since the resident's admission, and there was a lack of clarity among staff regarding the policy for PICC line management. The Director of Nursing (DON) and other staff members confirmed that there were no specific orders for the PICC line, and the facility did not provide a policy for PICC/IV dressing changes. The Centers for Disease Control and Prevention guidelines recommend changing PICC line dressings every seven days to prevent infection, but this was not adhered to, placing the resident at risk. The deficiency was identified through a combination of record reviews, staff interviews, and observations, highlighting a significant lapse in the facility's adherence to professional standards of practice for IV fluid administration.
Unsecured Medication and Treatment Carts
Penalty
Summary
The facility failed to ensure that medication carts and a respiratory treatment cart were securely locked when unattended, as observed on multiple occasions. On the morning of August 14, 2024, two medication carts and one respiratory treatment cart were found unlocked and unattended in various hallways. Specifically, Medication Cart #1 was left unlocked at the nursing station without any staff in view, and Medication Cart #2 was similarly unsecured in another hallway. The respiratory treatment cart was also found unlocked, facing outward in a hallway without staff supervision. Interviews with staff members, including LVNs and respiratory therapists, confirmed that the carts were supposed to be locked when not in use or under direct supervision. Staff acknowledged the potential risks of leaving the carts unlocked, such as unauthorized access to medications by residents or others. The facility's policy, as reviewed, clearly stated that medication and treatment carts must be locked when not in use or under direct supervision, highlighting a failure to adhere to established procedures.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to ensure proper notification procedures were followed before transferring or discharging a resident to the hospital. Specifically, the facility did not send a written notice of transfer or discharge, along with the reasons for the transfer, to the Office of the State Long-Term Care Ombudsman for one resident. This oversight was identified during a review of the resident's records and interviews with facility staff and the resident. The resident, a female with chronic respiratory failure and other health conditions, was transferred to the hospital after experiencing shortness of breath and chest pain. Despite the transfer, the resident did not receive any paperwork indicating she had been discharged, and the ombudsman confirmed not receiving any discharge notifications. Interviews with facility staff revealed confusion and lack of clarity regarding the responsibility for sending discharge notices, with different staff members providing conflicting information about their roles in the discharge process. The facility's policies require that a notice of transfer or discharge be provided to the resident, their representative, and the ombudsman, especially in cases of emergency transfers. However, the facility's administration and nursing staff did not adhere to these policies, resulting in the resident being discharged from the system without proper notification. The facility's failure to follow its own policies and procedures led to the deficiency identified in the report.
Failure to Provide Written Bed-Hold Policy Before Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed-hold policy to a resident or their representative before the resident was transferred to a hospital. This deficiency was identified during a review of the case of a resident who was transferred to an acute care hospital. The resident, who had a history of chronic respiratory failure, candidiasis, chronic obstructive pulmonary disease, and required a tracheostomy, was not given written information about the duration of the bed-hold policy prior to her transfer. The facility's records showed that the resident was discharged to the hospital, and upon her readiness to return, the facility did not have a bed available for her. Interviews with facility staff, including the Marketing Manager, Administrator, and DON, revealed that the facility does not hold beds in the trach unit or general unit, and beds are filled as soon as they become available. The facility's admission packet indicated that bed-hold information should be provided at admission and re-issued at the time of transfer, but this was not done in the resident's case. The resident's family was informed to pick up her belongings, and the hospital social worker confirmed that the facility stated they had no bed available for the resident upon her medical clearance to return.
Failure in Tracheostomy Care Leads to Resident's Health Decline
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, leading to significant health issues. The resident, a male with a history of acute respiratory failure, tracheostomy status, and other medical conditions, was found to have a tracheostomy tube cuff that was chronically overinflated. This overinflation was not in accordance with the manufacturer's recommended pressure of a maximum of 25 cmH2O. As a result, the resident experienced remodeling of the T1 and T2 vertebrae and swallowing difficulties, which likely contributed to starvation ketoacidosis. Interviews and record reviews revealed that the facility's staff, including the Lead Respiratory Therapist, were aware of the resident's requests for additional air in the tracheostomy cuff. Despite knowing the risks, some staff members reportedly complied with these requests to avoid upsetting the resident. The facility's Director of Nursing (DON) and other staff members were unaware of the overinflation issue, and there were no specific physician orders regarding the pressure for the tracheostomy tube cuff. The resident's refusal to eat and other care refusals were documented, but the connection between the overinflated cuff and the resident's inability to eat was not recognized until the resident was hospitalized. The resident's condition deteriorated to the point of being found unresponsive and hypotensive, leading to hospitalization. Hospital records indicated severe malnutrition and other complications related to the overinflated tracheostomy cuff. Interviews with facility staff, including the DON, Lead RT, and the resident's physician, highlighted a lack of communication and oversight regarding the resident's tracheostomy care. The facility's policy on tracheostomy care did not address cuff inflation, contributing to the oversight and subsequent health issues experienced by the resident.
Inadequate Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide adequate respiratory care for several residents, as observed during a survey. Resident #1, who required continuous respiratory oxygen therapy and CPAP use due to conditions such as acute respiratory failure and COPD, was found with undated oxygen tubing and a CPAP mask lying on the floor, unbagged and uncleaned. The resident's wheelchair, stored in the hallway, also had an oxygen tank with undated and unbagged nasal cannula tubing. These observations were made despite the resident's care plan indicating the need for careful monitoring and documentation of respiratory conditions. Similarly, Resident #3, who had severe cognitive impairment and required continuous oxygen treatment, was observed holding an undated nasal cannula, with additional tubing found on the floor, undated and unbagged. Resident #5, with moderate cognitive impairment and receiving oxygen therapy, had nasal cannula tubing wrapped around a bed rail and touching the floor, also undated and unbagged. Resident #7, who was cognitively intact and receiving oxygen treatment for COPD, was found with undated tubing connected to his oxygen concentrator and portable tank. Interviews with staff, including CNAs, RNs, and the ADON, revealed inconsistencies in the facility's practices regarding the dating, bagging, and changing of respiratory equipment. Staff acknowledged the importance of these practices for infection prevention but admitted to lapses in execution. The facility's policy did not mandate weekly tubing changes, instead requiring changes when tubing was visibly soiled or undated, which was not consistently followed, leading to potential risks of infection and inadequate respiratory care for the residents.
Failure to Update Resident Care Plan for Behavioral Changes
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plan for a resident, which did not reflect the resident's current status and behaviors. The resident, a male with severe cognitive impairment and multiple medical conditions including acute respiratory failure, emphysema/COPD, atrial fibrillation, and dementia, exhibited behaviors such as not using the call light when needing assistance, removing his CPAP mask, and throwing both the call light and CPAP mask to the floor when agitated. These behaviors were not addressed in the care plan, which could place the resident at risk of not receiving appropriate care and interventions. The resident's care plan, dated earlier in the year, did not include interventions for the resident's behaviors related to the call light and CPAP equipment. Despite observations and interviews indicating the resident's inability to use the call light and his actions of disassembling the CPAP hose, the care plan remained unchanged. Interviews with the ADON and DON revealed that the staff was aware of these behaviors, but the care plan was not updated to reflect these changes, which could lead to inadequate care. The facility's policy on comprehensive care planning emphasizes the need for person-centered care plans that address the resident's medical, physical, mental, and psychosocial needs. However, the failure to update the care plan for this resident indicates a lapse in following this policy. The DON acknowledged the oversight in updating the care plan, and the ADM was unaware of the resident's behaviors, highlighting a communication gap within the facility's staff regarding the resident's care needs.
Inaccessible Call Light Leads to Deficiency
Penalty
Summary
The facility failed to ensure that a working call system was available and accessible for a resident, which could place residents at risk of not receiving necessary care and services. Specifically, the call light for a resident was found on the floor and not within reach, despite the resident's care plan indicating the need for the call light to be accessible. The resident, who was severely cognitively impaired and required maximal assistance with activities of daily living, was observed to be agitated and stated that no one had come to help him out of bed. Interviews with staff revealed that the CNA was unaware of the call light being on the floor and mentioned that the resident often yelled for help instead of using the call light. The CNA also noted that the resident had a behavior of throwing the call light on the floor, but this behavior was not reported to the ADON or DON for further intervention. The charge nurse was also unaware of the call light's location and emphasized the importance of having the call light within reach for residents with confusion. The facility did not have a call light policy, and the DON and Administrator acknowledged the importance of residents being able to call for assistance in emergencies.
Delayed Reporting of Resident Fall Incident
Penalty
Summary
The facility failed to ensure the safety and well-being of Resident #1, who was found on the floor by Student Nurse Aide A during the 2:00 PM-10:00 PM shift on 04/09/24. Despite discovering Resident #1 on the floor at 9:46 PM, Student Nurse Aide A did not report the incident to the charge nurse until 4:40 AM the next day. This delay in reporting resulted in Resident #1 not receiving immediate treatment and care, including a nurse assessment, neurological checks, monitoring for possible serious injury, and timely physician notification. The resident, who had a history of dementia, diabetes, falls, and muscle weakness, was found to have significant bruising and injury to the right side of her face and head. The facility's failure to ensure proper protocols were followed when a resident was found on the floor led to a delay in necessary medical interventions for Resident #1. Despite having a care plan in place for fall prevention and interventions to ensure resident safety, the staff did not adhere to these guidelines effectively. The incident highlighted gaps in staff training and awareness, as evidenced by Student Nurse Aide A's lack of understanding of the appropriate actions to take when a resident is found on the floor. The subsequent interviews with staff members revealed confusion and miscommunication regarding the incident, indicating a breakdown in reporting and response procedures within the facility.
Failure to Implement Abuse/Neglect Policies Resulting in Delayed Care
Penalty
Summary
The facility failed to implement their written policies and procedures to prevent abuse, neglect, and exploitation of residents, as evidenced by the case of Resident #1. Student Nurse Aide A neglected to report to the charge nurse when she found Resident #1 on the floor, resulting in a significant delay in the resident receiving necessary treatment and care. This failure led to Resident #1 not being assessed by a nurse, not receiving neurological checks, monitoring for possible serious injury, and delayed notification to the physician. The facility's Abuse/Neglect policy clearly outlines the resident's right to be free from abuse and neglect, emphasizing the importance of timely reporting in cases involving abuse or serious bodily injury. Resident #1, an elderly female with a history of dementia, diabetes, falls, and muscle weakness, was found on the floor with significant bruising and injury to her face and head. Despite having a care plan in place to prevent falls and ensure resident safety, the failure of the staff to follow proper procedures resulted in Resident #1 being left unattended on the floor for an extended period. The facility's failure to ensure that staff members, especially Student Nurse Aide A, were adequately trained and aware of the correct protocols to follow in such situations directly contributed to the deficiency identified during the survey.
Inadequate Supervision Leads to Resident Elopement During Storm
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, a resident with severe cognitive impairment residing in the secure unit, leading to an incident where she wandered into the enclosed courtyard during a storm and was left outside for approximately 3 hours. Despite the resident's documented history of wandering behaviors and elopement risk, the facility did not adequately supervise her to prevent such incidents. The door leading to the courtyard, which required a code to open, was left unlocked or unsupervised when its locking mechanism lost power during the storm, allowing Resident #1 to exit without staff knowledge. This failure to provide adequate supervision put Resident #1 at risk of harm and exposed her to potential injury due to exposure to the elements. The deficiency was identified through a series of observations, interviews, and record reviews conducted by surveyors. Resident #1's medical history included diagnoses of dementia, diabetes, falls, hypertension, and muscle weakness, highlighting her vulnerability and need for close supervision. Despite the facility's care plan outlining interventions to prevent elopement, such as disguising exits, offering distractions, and closely supervising the resident, these measures were not effectively implemented in this instance. The incident report detailed Resident #1 being found lying on the ground in the courtyard, prompting a thorough investigation into the circumstances leading to her elopement.
Failure to Report Neglect and Delay in Treatment
Penalty
Summary
The facility failed to ensure that all alleged violations involving neglect were reported immediately, as required by regulations. Specifically, a student nurse aide found a resident on the floor but did not report the incident to the charge nurse. As a result, the resident did not receive immediate treatment and care until several hours later when another staff member discovered significant bruising and injury to the resident's face and head. The administrator also failed to report the incident to the appropriate state authorities after determining that the student nurse aide had neglected the resident by not notifying the charge nurse and placing the resident back in bed without an assessment. The resident involved was an elderly female with a history of dementia, diabetes, repeated falls, and other health issues. On the night of the incident, the resident was found on the floor by the student nurse aide, who then placed her back in bed without notifying the charge nurse. The resident was not assessed for injuries until the next shift, several hours later, when significant bruising and injury to her face and head were discovered. The delay in reporting and assessing the resident's condition resulted in a delay in treatment and care. Interviews with staff members revealed that the student nurse aide did not follow proper procedures for reporting falls and that there was a lack of communication between staff members regarding the incident. The facility's Director of Nursing (DON) and Administrator were aware of the incident but did not report it to the state authorities as required. The facility's policies on abuse, neglect, and reporting were not followed, leading to a deficiency in the care provided to the resident.
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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