Park View Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 3301 View St, Fort Worth, Texas 76103
- CMS Provider Number
- 455606
- Inspections on file
- 59
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at Park View Care Center during CMS and state inspections, most recent first.
Staff failed to follow hand hygiene practices during meal tray delivery, as multiple CNAs delivered lunch trays and entered resident rooms without using hand sanitizer or otherwise performing hand hygiene immediately beforehand. Several residents involved had complex medical conditions, including dementia, schizophrenia, respiratory failure, diabetes, and a history of severe sepsis, and some required setup or clean-up assistance for eating. Interviews with residents showed they were generally unaware of whether staff sanitized their hands, while staff interviews revealed inconsistent access to hand sanitizer, differing beliefs about who was responsible for maintaining sanitizer supplies, and acknowledgment that not sanitizing hands placed residents at risk of infection. The DON and Administrator confirmed expectations that staff perform hand hygiene and that hand sanitizer be available, and facility policies required proper hand hygiene for all direct resident contact, but observed practices during meal service did not comply with these policies.
Multiple rooms had broken window blinds with missing slats, allowing individuals outside to see into residents' beds and compromising privacy. Some residents expressed dissatisfaction with the lack of privacy. Staff, including a MA-C and an LVN, were unaware of the issue, and no repair requests were found in the Maintenance Logbooks. The Maintenance Director, responsible for repairs, also did not know about the broken blinds, despite the facility's policy emphasizing resident privacy and dignity.
A resident with multiple complex medical conditions and total dependence on staff was hospitalized for shortness of breath and, after receiving treatment, was twice denied reentry to the facility by administration. Despite behavioral concerns, there was no proper discharge process or safe alternative placement arranged, and staff interviews confirmed the resident was not provided with discharge documentation or a safe transition.
A resident with cognitive impairment, total dependence for ADLs, and a history of stroke and poor circulation developed an arterial wound that worsened over time. The care plan did not address the wound or the resident's non-compliance with care, despite staff efforts to educate and reposition her. Staff interviews confirmed ongoing challenges and lack of care plan updates to reflect the resident's needs and behaviors.
A resident with multiple complex diagnoses and hospice care orders had physician orders for PRN oxygen therapy, but staff failed to accurately document and code the oxygen treatment on the MDS. Despite care plans and orders indicating the need for oxygen, records showed no administration during the assessment period, and the facility could not provide its MDS policy when requested by surveyors.
A shower room was found with a blocked and soiled toilet, missing and torn shower curtains, and a leaking shower head hose, resulting in lack of privacy and unsanitary conditions. Staff interviews revealed that the issues were known but not reported, and facility leadership was unaware of the ongoing problems despite policies emphasizing resident privacy and dignity.
The facility did not maintain an effective pest control program, resulting in widespread gnats and flies in multiple areas, including hallways, nurse's stations, the dining room, and the biohazard closet. Residents and staff reported persistent pest issues, with some residents avoiding common areas due to the nuisance. Observations found improperly contained biohazard waste and unclear staff responsibility for cleaning, contributing to the infestation.
A nurse failed to maintain sterile technique during tracheostomy care for a resident on enhanced barrier precautions for ESBL, using non-sterile saline and contaminating the sterile field without restarting the procedure. The resident, who had multiple complex medical conditions and required full assistance, was at risk due to these lapses. Staff interviews revealed inconsistent adherence to sterile technique and gaps in policy familiarity and training.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with multiple medical conditions did not receive a scheduled colonoscopy after a provider order was issued. Although the referral was faxed to an outside provider, there was no documentation of follow-up or confirmation of an appointment, and the resident was not informed of any scheduled procedure. Interviews confirmed that social services was responsible for arranging and following up on such appointments, but the process was not completed or documented.
A Wound Care Nurse failed to wear a gown while providing wound care to a resident on enhanced barrier precautions for a chronic wound, despite clear signage and available PPE. The nurse only wore gloves during the procedure, contrary to facility policy and infection control expectations.
A resident with a history of violent behavior struck another resident in the face at the nurse's station, resulting in redness and requiring ice treatment. The assaulted resident, who has dementia and moderate cognitive impairment, was not protected from abuse despite the facility's policies. The assailant, with severe cognitive impairment and a history of aggression, was taken into custody for a mental health evaluation and did not return to the facility.
A facility failed to assist a resident with severe cognitive impairment in obtaining a follow-up dental appointment for a root canal due to a delay in processing payment to the dentist. The resident experienced dental pain and was only receiving pain medication without further intervention. The facility's social worker did not follow up on the dentist's invoice, leading to a delay in care, contrary to the facility's policy of ensuring continuous care.
A resident was prescribed Seroquel for Schizoaffective disorder, a condition he did not have, in violation of the facility's psychotropic management policy. Despite attempts at Gradual Dose Reduction, the medication was continued without a proper diagnosis, as confirmed by the DON.
The facility failed to maintain an effective pest control program, resulting in a roach infestation affecting several residents. Observations and interviews revealed roaches in multiple resident rooms and common areas, despite weekly visits from a pest control vendor. Staff and residents reported the issue, but measures taken were ineffective, indicating a failure to implement a successful pest control strategy.
Two residents with severe cognitive impairments were fed by staff members who stood while assisting them, contrary to their care plans and facility policy. A CNA and an LVN admitted to not being trained on the importance of sitting during feeding to promote dignity and prevent aspiration. The DON and ADON confirmed that staff should sit at eye level with residents during feeding.
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans. One resident, with significant impairments, was found with her call light attached to the wall and inaccessible, while another resident's call light was tangled under her bed. Staff interviews confirmed the oversight and the facility's policy mandates that call lights be accessible to residents.
A resident with respiratory failure was observed receiving 5 LPM of oxygen instead of the physician-ordered 3 LPM. Despite the facility's policy to follow physician orders, staff failed to administer the correct oxygen level, as confirmed by interviews with RN C, the DON, and the ADON.
A resident with a gastrostomy tube did not receive medications according to prescribed protocols, as LVN D failed to dissolve medications and flush the tube with the correct amount of water. This led to the tube clogging and improper administration of the bolus formula. The resident's care plan required specific procedures due to risks of aspiration and dehydration, which were not followed, as confirmed by interviews with LVN D and the DON.
A facility exceeded the acceptable medication error rate with a 6.06% error rate during a medication pass by an LVN. The LVN failed to dissolve medications properly and left residue in cups, leading to incomplete doses for a resident with a gastrostomy tube. The resident's complex medical history required specific medication administration procedures, which were not followed, resulting in a clogged g-tube. Interviews revealed a lack of awareness and adherence to physician orders and facility policies.
A resident with a history of stroke and right-sided weakness was provided with a bed that had non-functional wheel locks, posing a fall risk. Despite the resident's request for a replacement, the issue was not addressed until after a surveyor's visit, violating the resident's right to a safe environment.
A resident at a LTC facility experienced verbal abuse from the Administrator, who used inappropriate language during a conversation about facility conditions. The resident, who had no cognitive impairment and specific medical conditions, felt unsafe and left the facility. The incident was confirmed through an audio recording and interviews, highlighting a failure to protect residents from abuse.
A resident at a long-term care facility experienced verbal abuse from the Administrator, who used inappropriate language during a conversation about facility conditions. The resident, who had no cognitive impairment and a history of paraplegia, felt unsafe and left the facility. The incident was recorded and confirmed by the DON and the Administrator, who later suspended himself pending an investigation.
The facility failed to maintain a safe and comfortable environment in two dining rooms, with chairs in poor condition, including ripped and frayed seat cushions with exposed foam. Residents expressed discomfort and dissatisfaction, and despite complaints to the administration, no action was taken. The Maintenance Director and Administrator acknowledged the issue, citing cost concerns, but maintenance logs showed no related entries.
Failure to Ensure Hand Hygiene During Meal Tray Delivery
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff performed appropriate hand hygiene during meal service, as required by its infection prevention and control program and hand hygiene policy. During a lunch meal delivery on Hall 100, multiple CNAs passed meal trays to residents without using hand sanitizer or otherwise performing hand hygiene immediately before resident contact. Observations on 03/05/26 at approximately 12:19 PM showed two CNAs knocking on doors and entering rooms to deliver meal trays to two residents without sanitizing their hands beforehand. At 12:23 PM, another CNA exited the shower room and began assisting with meal tray distribution without sanitizing her hands. At 12:25 PM, this same CNA adjusted her clothing by pulling on her pants and then continued pushing the meal cart and delivered a tray to another resident. At 12:27 PM, she handed a tray to a fourth CNA, who took the tray into another resident’s room without sanitizing her hands. The residents involved had various medical and functional profiles documented in their records. One male resident had a history of traumatic subarachnoid hemorrhage, major depressive disorder, and anxiety disorder, and required setup or clean-up assistance for eating, with a care plan goal to maintain dignity by being clean, dry, odor free, and well groomed. Another male resident had dementia, peripheral vascular disease, schizophrenia, major depressive disorder, and hypertension, and was care planned for ADL self-care performance deficit related to dementia, with interventions including setup and supervision for eating; his MDS indicated he could eat independently. A third male resident had dementia, paranoid schizophrenia, encephalopathy, anxiety disorder, hypertension, and respiratory failure, and was care planned as being at risk for infection and viral respiratory infection, with interventions including education on signs, symptoms, and precautions. A female resident had type 2 diabetes, severe sepsis, schizophrenia disorder, cognitive communication deficit, and bipolar disorder, and was also care planned as being at risk for infection and viral respiratory infection with similar educational interventions. Several of these residents required setup or clean-up assistance for eating, meaning staff were expected to handle their meal trays and related items. Interviews with residents and staff further described the circumstances surrounding the lack of hand hygiene. Two cognitively intact male residents reported they did not know whether staff sanitized their hands before bringing food into their rooms; one stated staff did not wash their hands before leaving his room, and both acknowledged that clean hands were important, though they reported not having been sick. One cognitively intact female resident was unable to provide relevant information about staff hand hygiene during an interview, instead giving unrelated responses. Staff interviews revealed inconsistent access to and use of hand sanitizer: one CNA stated she did not use hand sanitizer when passing trays and reported that hallway sanitizer stations did not work, claiming she had informed nurses but did not receive sanitizer. Another CNA stated there was no or mostly empty hand sanitizer in the hall, that she usually washed her hands when passing and picking up trays, and that she had washed her hands in the shower room and therefore did not see a need to sanitize again; she denied reporting the lack of sanitizer. A third CNA stated staff were supposed to carry hand sanitizer in their pockets and believed there were sanitizer containers on the halls but would need to check, and she thought housekeeping was responsible for ensuring availability. The DON reported she was new, believed staff should have hand sanitizer at all times, was unsure about the presence of sanitizer receptacles in the halls, and denied being told sanitizer was unavailable. The Administrator stated the expectation was that CNAs practice good hand hygiene and notify her if sanitizer was not available. Facility policies on infection control and hand hygiene required staff involved in direct resident contact to perform proper hand hygiene to prevent the spread of infection, but observations and interviews showed this was not consistently implemented during meal service for the four residents. The facility’s own staff acknowledged that failure to sanitize hands placed residents at risk of infection, cross contamination, and transfer of bacteria. CNAs interviewed stated that residents were at risk of transmission of infection when staff did not sanitize their hands, and the DON stated that when staff did not sanitize their hands they placed residents at risk of transmission of infection. The Administrator similarly stated that residents had been at risk of getting sick with infection or a UTI. These statements, combined with the observed lack of hand hygiene during meal tray delivery and the documented policies requiring hand hygiene, form the basis of the identified deficiency in the facility’s infection prevention and control program. The infection control and prevention in-service record dated 1/5/26 stated that the purpose of the policy was to reduce the spread of infections by using evidence-based techniques and established infection control policies and procedures, and that it was the policy to use precautions to reduce the risk and prevent transmission of infectious agents. The hand hygiene policy dated 11/12/17 specified that staff involved in direct resident contact would perform proper hand hygiene procedures to prevent the spread of infection to personnel, residents, and visitors, and defined hand hygiene as either handwashing or use of an alcohol-based hand rub, to be performed when indicated using proper technique consistent with accepted standards of practice. Despite these written policies and in-service education, the observed practices during the lunch meal service on Hall 100 did not align with the facility’s stated infection prevention and control requirements, resulting in the cited deficiency.
Failure to Maintain Resident Privacy Due to Broken Window Blinds
Penalty
Summary
The facility failed to ensure full visual privacy for residents in six rooms, as window blinds in these rooms had multiple broken slats, allowing individuals outside the facility to see into the residents' beds. Observations on several occasions revealed varying numbers of broken slats in the blinds of these rooms, with some residents expressing dissatisfaction and concern about the lack of privacy. One resident specifically stated that the blinds had been broken for a long time and needed replacement for privacy, while another resident disliked the broken blinds because they allowed people to see inside. Interviews with staff, including a medication aide and an LVN, revealed that they were unaware of any blinds needing replacement and that repairs were typically entered into a Maintenance Logbook at each nurses' station. Review of the Maintenance Logbooks showed no requests for blind repair or replacement. The Maintenance Director stated he was responsible for physical plant repairs and relied on staff to report issues, checking the logbooks regularly and conducting monthly room sweeps. He was unaware of the broken blinds but indicated that replacements were available. The facility's policy emphasized the importance of privacy and dignity for residents, including maintaining a homelike environment.
Failure to Permit Safe Return and Proper Discharge After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to permit a resident to return after a hospitalization, despite the resident requiring extensive assistance with all activities of daily living and having multiple complex medical conditions, including diabetes mellitus, chronic respiratory failure, COPD, major depressive disorder, end stage renal disease, morbid obesity, and a history of seizures. The resident was dependent on staff for care and had a care plan addressing resistance to care, dialysis needs, diabetes management, and congestive heart failure. The resident was sent to the hospital for shortness of breath and chest pain, received necessary treatment, and was cleared for return to the facility on two separate occasions. Upon both attempts to return from the hospital, emergency services and hospital staff reported that the facility refused to readmit the resident. The facility staff, including the Administrator, cited the resident's history of refusing care, medications, and dialysis, as well as being rude and abusive towards staff, as reasons for not allowing reentry. Despite these behavioral concerns, there was no documentation of a proper discharge process, and the resident was not provided with a safe alternative placement. Interviews with facility staff, emergency medical technicians, hospital staff, and the Ombudsman confirmed that the resident was denied reentry and that no discharge paperwork or safe discharge planning was completed. The facility's own policy on discharge planning did not address the process for allowing residents to return after a hospital visit. Multiple staff members, including the ADON and nurses, indicated they were unaware of any formal discharge and anticipated the resident's return. The Administrator acknowledged that the resident was not properly discharged and would not be allowed to return, despite understanding that this placed the resident at risk of not having a safe place to live and receive necessary care. The lack of proper discharge documentation and refusal to readmit the resident constituted a failure to ensure a safe and appropriate transfer or discharge.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Wound and Non-Compliance
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a stroke, poor circulation, and nicotine dependence. The resident was moderately cognitively impaired, totally dependent on staff for activities of daily living, and at risk for pressure ulcers. Despite developing an arterial wound on her left outer ankle, the care plan did not address the wound or the resident's non-compliance with care instructions. Assessments showed the wound worsened over time, and documentation from the wound physician linked poor healing to the resident's smoking and failure to offload pressure. Interviews with staff revealed ongoing challenges in managing the resident's care, including her preference to remain in bed, resistance to repositioning, and repeated removal of positioning aids. Staff and family attempted to encourage mobility and offloading of pressure, but the resident remained largely non-compliant, expressing disbelief in the education provided. The care plan was not updated to reflect these issues, and the Assistant Director of Nursing acknowledged being behind on care plan updates due to being new in the role.
Failure to Accurately Document and Code Oxygen Therapy on MDS
Penalty
Summary
Facility staff failed to ensure that clinical records for a resident were accurately documented in accordance with accepted professional health information management standards. Specifically, the facility did not properly code the resident's oxygen treatment on the Minimum Data Set (MDS), despite the resident having physician orders for PRN oxygen therapy due to respiratory conditions and being on hospice care. The resident's care plan and physician orders indicated the need for oxygen therapy, and staff were expected to document administration and refusals, as well as notify appropriate personnel when the resident refused treatment. Record reviews revealed that the resident had a history of refusing care and treatment, including oxygen therapy. Interviews with facility staff, including the Hospice RN, NP, ADON, DON, and MDS coordinators, confirmed that the resident had an active order for PRN oxygen and that refusals were to be documented and reported. However, during the lookback period for the MDS, the resident had not received oxygen treatment, and the last documented administration was prior to the most recent physician order. The Treatment Administration Record (TAR) did not reflect any oxygen administration during the relevant period, and the MDS was not coded to indicate oxygen therapy. Additionally, the facility was unable to provide its MDS policy protocol when requested by the surveyor, despite assurances that it would be sent. The administrator acknowledged awareness of the resident's resistance to care and stated that staff were expected to follow facility policy and physician orders. The failure to accurately document and code the resident's oxygen therapy on the MDS constituted a deficiency in maintaining clinical records according to professional standards.
Failure to Maintain Safe, Sanitary, and Private Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of three shower rooms on Central Station. Observations revealed that the toilet in the shower room was blocked by equipment and had a dark substance with an odor. The right-side shower had a torn curtain, limiting privacy, while the left-side shower lacked a curtain entirely, resulting in no privacy for residents. Additionally, the shower head hose on the left side had holes, causing water to leak out the side. These issues were directly observed during a facility survey. Interviews with staff indicated that the CNA working in the area was aware of the missing and damaged shower curtains and broken shower head but had not reported the issues. The CNA stated that such damages should be reported to nursing and maintenance via the maintenance log book. The Maintenance Director confirmed that curtains had been recently ordered and replaced but was unsure why they were disappearing, and stated that nursing staff were responsible for logging maintenance concerns. The DON and Administrator were not aware of the ongoing issues, and both indicated that it was the responsibility of nursing staff to report problems and for maintenance and housekeeping to address them. Record review of the facility's policy emphasized the importance of privacy, dignity, and a homelike environment for residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and flies throughout multiple areas, including all three hall locations, nurse's stations, the Central Station dining room, and the biohazard closet. Observations revealed gnats circling in the Central Station shower room and dining room, as well as flies and gnats flying around the Central Station nursing station. Residents reported being frustrated by the persistent presence of pests, with some choosing to eat in their rooms to avoid them. Staff interviews confirmed that flies and gnats were a widespread issue, with several residents keeping fly swatters in their rooms and expressing dissatisfaction with the living conditions. Further investigation into the biohazard closet revealed a significant infestation of gnats and flies, with dead insects found on the floor and shelves, and biohazard waste not properly contained. The closet was found to be in disarray, with open and improperly sealed biohazard bags and boxes, and a lack of clear responsibility for maintaining cleanliness. Staff interviews indicated confusion and lack of accountability regarding who was responsible for monitoring and cleaning the biohazard closet, leading to the accumulation of waste and pest infestation. The maintenance director acknowledged ongoing concerns with pests, citing contributing factors such as standing water outside the building, frequent opening of the smoke patio door, and delayed removal of biohazard waste. The pest control vendor was reported to be treating the facility weekly, but staff noted inconsistent presence of the vendor. The facility's pest control policy required regular and as-needed pest control services, but observations and interviews indicated that these measures were not effectively implemented, resulting in continued pest problems and negative impact on residents' quality of life.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the provision of tracheostomy care for a resident on enhanced barrier precautions due to ESBL colonization. During an observed tracheostomy care procedure, a nurse did not set up all necessary supplies beforehand and used a previously opened, non-sterile saline bottle instead of sterile saline as required by policy. The nurse also broke sterile technique by reaching into the resident's bedside table with sterile gloves to retrieve additional supplies and did not stop the procedure after contaminating the sterile field. The resident involved had multiple complex medical conditions, including a tracheostomy, hemiplegia, stroke, dysphagia, and depression, and required assistance with all activities of daily living. The care plan indicated the resident was at high risk for further cognitive impairment and psychosocial issues. The resident was on enhanced barrier precautions due to ESBL colonization and required regular tracheostomy care and suctioning every nursing shift. Interviews with facility staff revealed gaps in adherence to sterile technique and inconsistencies in training and competency checks. The nurse involved acknowledged the breach in sterile field and the failure to restart the procedure with new supplies. The DON and a respiratory consultant both indicated that tracheostomy care training was provided, but there was a lack of familiarity with current facility policies and procedures. Review of the facility's tracheostomy care and suctioning policies confirmed the requirement for sterile technique and the use of sterile supplies.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Ensure Follow-Up and Scheduling of Medically Necessary Colonoscopy
Penalty
Summary
The facility failed to provide medically related social services necessary for a resident to achieve the highest practicable well-being by not ensuring a colonoscopy referral was properly followed up and scheduled. The resident, a female with a history of diabetes mellitus, cerebrovascular accident, transient ischemic attack, and non-Alzheimer's dementia, had a physician's order for a GI consult and colonoscopy. Documentation showed that the order was communicated to social services, and referral packets were faxed to the outside provider on multiple occasions. However, there was no evidence that an appointment was ever scheduled or that follow-up communication with the provider was documented. Interviews with the resident revealed she was informed months prior that a colonoscopy was recommended but was never given an appointment date or further information. The social worker and social worker assistant confirmed their roles in handling outside provider appointments, with the assistant responsible for sending referrals and following up. Despite sending the referral, the assistant had no documentation of any follow-up calls or actions taken after the initial fax, and the resident remained unaware of any scheduled appointment. Further interviews with nursing staff and the DON clarified that the process involved the NP writing the order, nursing communicating it to social services, and social services arranging the appointment and transportation. The DON stated that social services was expected to ensure appointments were scheduled and to follow up as needed. Despite these established responsibilities and policies, the lack of documented follow-up and communication resulted in the resident not receiving the ordered colonoscopy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a Wound Care Nurse not wearing a gown while providing wound care to a resident on enhanced barrier precautions. The resident, a male with a history of cellulitis, lymphedema, and chronic venous hypertension with ulcers, was care planned for enhanced barrier precautions due to a vascular ulcer. Despite clear signage outside the resident's room and the availability of gowns in the room, the Wound Care Nurse only donned gloves and did not wear a gown while applying a bandage to the resident's leg. Interviews revealed that the Wound Care Nurse was initially unaware or had forgotten that the resident was on enhanced barrier precautions, despite prior training and the presence of a posted sign. The facility's Infection Preventionist and DON confirmed that all staff were expected to follow infection control procedures, including wearing gowns and gloves for residents on enhanced barrier precautions. The facility's policy required the use of gowns and gloves during high-contact care activities for residents with chronic wounds, which was not followed in this instance.
Resident Assault and Facility's Failure to Prevent Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when another resident struck him in the face. The incident occurred at the nurse's station where the first resident was eating a snack, and the second resident approached to get a snack as well. The first resident made a statement to the second resident, who then struck him on the left cheek with a closed fist. This resulted in redness to the first resident's cheek, and ice was applied to the affected area. The second resident also received ice for his right fist as a precautionary measure. The residents were immediately separated and treated in their rooms. The first resident, a male with dementia, stroke, and an amputation, had a moderate cognitive impairment and no history of aggression. The second resident, a male with a traumatic brain injury, schizoaffective disorder, and a history of violent behavior, had severe cognitive impairment. Despite his behavioral assessment indicating no issues, the second resident had previously made accusations and complaints about other residents. On the day of the incident, the second resident was verbally aggressive before physically assaulting the first resident. The facility's investigation revealed that the second resident had a history of violent behavior and showed no remorse for his actions. The police were called, and the second resident was taken into custody for a mental health evaluation and did not return to the facility. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from harm, but the incident demonstrated a failure to prevent abuse and ensure the safety of all residents.
Failure to Ensure Timely Dental Care Due to Payment Delay
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental care, specifically a follow-up appointment for a root canal, due to a delay in processing payment to the dentist. The resident, a male with severe cognitive impairment and a history of a vehicle accident causing brain injury, was experiencing dental pain but was only receiving pain medication without further dental intervention. Despite the resident's expressed desire to see the dentist again, the facility did not ensure timely payment for a previous dental visit, which resulted in the dentist refusing further treatment until the invoice was settled. The resident's records indicated that he had been seen by the dentist previously, where fillings were done, and he was informed that a root canal might be necessary if pain persisted. However, the facility's social worker failed to follow up on the dentist's invoice, leading to a delay in the resident's dental care. The facility's policy required assistance in making appointments and ensuring continuous care, but this was not adhered to, resulting in the resident potentially experiencing unnecessary dental pain.
Inappropriate Prescription of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was not given psychotropic medications unless necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident, a male with a history of dementia, stroke, and unspecified psychosis, was prescribed Seroquel for a condition he did not have, specifically Schizoaffective disorder. The resident's admission record and care plan did not include a diagnosis of Schizoaffective disorder, yet the medication was prescribed for this condition. The resident had been on Seroquel since 2012 for unspecified psychosis, and the medication was later prescribed for Schizoaffective disorder without a proper diagnosis. The Director of Nursing (DON) confirmed that the resident did not have a diagnosis of Schizoaffective disorder but stated that the medication was necessary due to worsening behaviors when attempts were made to wean the resident off Seroquel. Despite several unsuccessful attempts at Gradual Dose Reduction (GDR), the facility continued the medication without a documented diagnosis of Schizoaffective disorder. The facility's policy on psychotropic management requires that such medications are only given when necessary to treat a specific condition as diagnosed and documented, which was not adhered to in this case.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a significant roach infestation affecting six residents. Observations and interviews revealed that roaches were present in multiple resident rooms, including those of Residents #56 and #99, where roaches were seen along baseboards and behind dressers. Residents reported finding roaches in their personal items, such as cups, and expressed frustration over the lack of effective action despite reporting the issue to staff multiple times. Further observations noted roaches crawling across floors and walls in various areas of the facility, including the South Station and resident rooms. Housekeeping staff and maintenance personnel acknowledged the presence of roaches and reported the issue to their supervisors. Despite the pest control vendor's weekly visits, the problem persisted, with staff and residents continuing to encounter roaches in living areas, which were also observed by surveyors during their inspection. Interviews with staff, including housekeeping, maintenance, and nursing personnel, confirmed the ongoing roach problem. The maintenance department had a procedure for addressing pest issues reported in a logbook at the nursing station, but the measures taken, including spraying and notifying the pest control vendor, were ineffective. The facility's pest control policy aimed to eradicate pests using appropriate chemicals, but the continued presence of roaches indicated a failure to implement an effective pest control strategy.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during feeding assistance. Resident #82, a female with severe cognitive impairment and a diagnosis of dysphagia following a nontraumatic intracerebral hemorrhage, was fed by CNA A while the CNA stood beside her bed. This action was contrary to the resident's care plan, which required supervised assistance by one staff member. CNA A admitted to not knowing the importance of sitting while feeding and had not received training on this aspect of care. Similarly, Resident #109, a female with severe cognitive impairment and multiple sclerosis, was fed by LVN B while standing in the dining room. The resident's care plan required extensive assistance by one staff member. LVN B acknowledged knowing the importance of sitting to prevent aspiration and promote dignity but had not received specific training on this practice. The Director of Nursing and Assistant Director of Nursing confirmed that staff were expected to sit at eye level with residents during feeding to ensure dignity and proper pacing, but this expectation was not met in these instances.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #26 and Resident #34, had their call lights within reach, which is a necessary accommodation for their needs and preferences. Resident #26, a female with significant impairments including cerebral infarction, aphasia, and hemiplegia, was observed with her call light string not within reach while she was in bed. Her care plan specifically required that the call light be within reach to ensure her needs could be met promptly. Despite this, the call light was attached to the wall and not accessible to her, as confirmed by a CNA who acknowledged the oversight and the potential risk of unmet needs. Similarly, Resident #34, who also had significant mobility and communication impairments, was found with her call light not within reach. The call light was tangled underneath her bed, making it inaccessible. Her care plan also emphasized the importance of having the call light within reach to prevent falls and ensure her needs were met. A CNA responsible for her care admitted to not noticing the call light's position and acknowledged the importance of having it accessible. Interviews with staff, including CNAs and the DON, revealed a consensus that it was the responsibility of all staff to ensure call lights were within reach. The facility's policy also mandated that call lights be placed near residents and never on the floor or bedside stand. The failure to adhere to these policies and care plans placed the residents at risk of injuries and unmet needs, as they were unable to call for assistance when required.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The facility failed to administer oxygen therapy to a resident as ordered by the physician, which is a deficiency in providing appropriate respiratory care. Resident #102, who was admitted with a diagnosis of respiratory failure and required oxygen therapy, was observed receiving 5 liters per minute (LPM) of oxygen via nasal cannula, contrary to the physician's order of 3 LPM. This discrepancy was noted during multiple observations throughout the day, and the resident was unaware of the correct oxygen level he was supposed to receive. Interviews with the nursing staff, including RN C and the Director of Nursing (DON), revealed that the staff were expected to follow physician orders for oxygen therapy. However, RN C acknowledged the failure to administer the correct oxygen level and expressed concern about the potential harm of excessive oxygen. The DON and Assistant Director of Nursing (ADON) also confirmed the expectation for staff to check and ensure the correct oxygen levels at the start of each shift, but the ADON admitted to not checking the oxygen level during rounds. The facility's policy on following physician orders was reviewed, indicating a requirement to carry out and implement physician orders.
Failure to Follow Medication Administration Protocols for G-Tube
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident with a gastrostomy tube. LVN D did not follow the facility's policy for flushing the gastrostomy tube with the prescribed amount of water before, between, and after administering medications. Specifically, LVN D administered Vitamin D, Magnesium Oxide, and Sodium Chloride to the resident without dissolving the medications in water as required and did not flush the tube with the correct amount of water between medications. The resident involved was an elderly female with a history of cerebral infarction, cognitive communication deficit, and other related conditions, including gastrostomy status. Her care plan indicated she was at risk for aspirations, weight loss, and dehydration, and required specific procedures for medication administration via her feeding tube. Despite these requirements, LVN D failed to dissolve the medications and used a plunger to administer the bolus formula instead of allowing it to flow by gravity, which led to the gastrostomy tube clogging. Interviews with LVN D and the Director of Nursing (DON) revealed that LVN D was unaware of the specific physician orders for dissolving medications and flushing the tube with the prescribed amount of water. The DON confirmed that the expectation was for nurses to follow physician orders and administer medications and formula via gravity. The facility's policy required verification of medication administration accuracy and adherence to physician orders, which was not followed in this instance.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 6.06%, exceeding the acceptable threshold of 5%. This was observed during a medication pass by LVN D, who was responsible for administering medications to a resident via a gastrostomy tube. The errors were identified when LVN D failed to dissolve the medications properly and did not administer the full contents of the medication cups, leaving residue behind. This resulted in the resident not receiving the full prescribed doses of their medications. The resident involved was a female with a complex medical history, including cerebral infarction, cognitive communication deficit, and gastrostomy status, among other conditions. Her care plan required specific procedures for medication administration via a feeding tube, including dissolving each medication with water and flushing the tube between medications. However, LVN D did not adhere to these procedures, leading to a clogged g-tube and incomplete medication administration. Interviews with LVN D and the Director of Nursing (DON) revealed a lack of awareness and adherence to the physician's orders and facility policies regarding medication administration. LVN D admitted to not dissolving the medications as required and acknowledged the presence of medication residue in the cups. The DON confirmed that the expectation was for nurses to follow the prescribed procedures to ensure effective medication delivery, highlighting a gap in staff training and oversight.
Failure to Provide Safe Bed Equipment
Penalty
Summary
The facility failed to maintain safe operating conditions for mechanical and patient care equipment, specifically for a resident who was provided with a bed that had non-functional wheel locks. This deficiency was identified during an observation and interview with the resident, who was a cognitively intact female with a history of stroke, resulting in right-sided weakness and requiring extensive assistance with transfers. The resident expressed fear and reluctance to attempt self-transfers due to the bed's inability to lock, which posed a risk of falls. The resident reported that the bed had not locked since her admission and that she had requested a replacement from the nursing staff, which had not been addressed until after the surveyor's visit. The facility's failure to provide a bed with functional wheel locks was in violation of the resident's right to a safe environment, as outlined in the facility's Resident Rights policy.
Verbal Abuse by Administrator
Penalty
Summary
The facility failed to protect a resident from verbal abuse by the Administrator, which was identified through observation, interview, and record review. The incident involved a male resident who was admitted to the facility with a BIMS score indicating no cognitive impairment and had diagnoses including paraplegia and hyponatremia. The resident's care plan noted a risk for harm due to verbally abusive behaviors, and interventions included approaching the resident calmly and speaking slowly. The deficiency was highlighted by an audio recording provided by the resident, which captured a conversation between the resident and the Administrator. During the conversation, the Administrator used inappropriate language, including curse words, and dismissed the resident's concerns about the temperature in the facility. The resident expressed feeling unsafe and scared after the interaction, which led to his decision to leave the facility. The recording revealed the Administrator's dismissive and derogatory remarks, which were considered verbally abusive by the Director of Nursing (DON). Interviews with the DON and the Administrator confirmed that cursing at a resident is considered abuse. The Administrator, who was also the Abuse Coordinator, initially denied recalling the use of curse words but later acknowledged the possibility after listening to the recording. Despite the Administrator's claim that the language was used to communicate effectively with the resident, the facility's policy clearly defined such behavior as verbal abuse, emphasizing the need for a safe and comfortable environment for residents.
Verbal Abuse Incident by Administrator
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving verbal abuse directed at a resident by the Administrator. The incident involved a conversation between the Administrator and a resident, during which the Administrator used inappropriate language, including curse words, towards the resident. This interaction was recorded by the resident, who later provided the audio as evidence of the verbal abuse. The resident involved in the incident was a 44-year-old male with a history of paraplegia and hyponatremia, who had been admitted to the facility earlier in the year. The resident had a BIMS score indicating no cognitive impairment and had expressed dissatisfaction with the facility, citing feelings of being unwanted and unsafe. The resident reported that the Administrator cursed at him during a conversation about the temperature in the facility, which made him feel scared and led to his decision to leave the facility. Interviews with the Director of Nursing (DON) and the Administrator confirmed that cursing at a resident is considered abuse. The Administrator, who also served as the Abuse Coordinator, initially denied recalling the use of curse words but later acknowledged the possibility after listening to the recording. Despite this acknowledgment, the Administrator attempted to justify his language as a means of communication with the resident, who frequently interrupted him. Ultimately, the Administrator suspended himself from his duties pending an investigation into the abuse allegation.
Facility Fails to Maintain Safe and Comfortable Dining Room Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in two of its dining rooms, specifically the Main Dining Room and the North Station Dining Room. Observations revealed that chairs in these areas were in poor condition, with ripped, cracked, and frayed seat cushions, some of which had exposed foam. Residents expressed discomfort and dissatisfaction with the chairs, noting that they were uncomfortable and unsightly. Interviews with residents, including the Resident Council president, indicated that complaints had been made to the facility's administration, but no action had been taken to address the issue. The Maintenance Director acknowledged the poor condition of the chairs and stated that the facility was considering options for repair or replacement, but no decision had been made. The Director of Nursing (DON) and the Administrator were aware of the issue, with the Administrator citing cost concerns as a reason for the lack of action. Despite the acknowledgment of the problem, maintenance logs showed no entries related to the condition of the chairs, and the facility's policy on housekeeping standards emphasized the importance of maintaining a clean, safe, and pleasant environment, which was not upheld in this case.
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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