Wedgewood Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 6621 Dan Danciger Rd, Fort Worth, Texas 76133
- CMS Provider Number
- 455572
- Inspections on file
- 44
- Latest survey
- June 18, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Wedgewood Nursing Home during CMS and state inspections, most recent first.
During a lunch meal, pureed rice pilaf was served with chunks and not at the required pudding-like consistency for residents on pureed diets. The DM did not verify the texture of the pureed food, and the staff member responsible acknowledged the rice was not smooth but served it anyway, contrary to facility policy.
A resident with multiple complex medical conditions experienced a change in condition resulting in hypoglycemia and hospital transfer. The facility failed to document the times for blood glucose monitoring, medication administration, and contacts with the NP and EMS. Staff interviews confirmed the importance of timely and complete documentation, and facility policy required such entries to be objective, chronological, and include all relevant details.
A facility failed to ensure proper treatment for a resident receiving enteral feeding, leading to a deficiency. A nurse used a de-clogger tool on a g-tube without physician orders, and the facility did not follow the prescribed water flush schedule, risking g-tube clogging. The resident had multiple medical conditions, requiring careful management of his feeding tube.
A facility with over 120 beds failed to employ a full-time social worker since late September 2024, as confirmed by resident interviews and record reviews. The absence of a social worker was acknowledged by the new Administrator, who stated that other staff members were addressing social service needs in the interim. The facility did not have a policy for social services.
The facility failed to provide adequate privacy curtains for several residents, leading to a lack of visual privacy during personal care. Observations showed that a resident had a curtain hanging by only four hangers, while another had no curtain at the foot of the bed. Staff interviews revealed a lack of awareness and responsibility for ensuring curtains were in place, and the facility lacked a specific policy on resident privacy.
A resident with severe cognitive impairment and physical limitations did not receive necessary nail care, resulting in untrimmed, jagged nails with a black substance underneath. Despite the resident's care plan indicating a need for extensive assistance with personal hygiene, observations showed her nails remained untrimmed over consecutive days. Staff interviews revealed that CNAs were responsible for nail care unless the resident had diabetes, but the facility's nail care policy was not followed.
A resident with a right hand contracture did not receive appropriate treatment as the facility failed to ensure the use of a splint or palm guard. The resident, with a history of aphasia and hemiplegia, was observed without a contracture management device for several days. Staff interviews revealed a lack of awareness and documentation regarding the use of the splint, and there was no physician's order in place, contrary to facility policy.
A facility failed to ensure physician orders for a resident's tracheostomy care, including suction tubing and an emergency trach kit. The resident, with a history of cerebral artery issues and respiratory failure, was admitted with a tracheostomy, but necessary orders were missing. Nursing staff continued care without orders, potentially leading to inadequate care. Facility policies requiring verification of physician orders were not followed.
The facility failed to prepare pureed mashed potatoes to the required pudding consistency for residents on pureed diets. The Dietary Manager used a whisk instead of a blender, resulting in lumpy potatoes, which could pose a choking risk. The facility's guidelines require a smooth consistency to prevent swallowing difficulties.
A facility failed to maintain an effective infection control program when a medical assistant did not sanitize a reusable blood pressure cuff between uses on two residents. Both residents required assistance with ADLs and had cognitive awareness. The medical assistant admitted to forgetting to sanitize the cuff, and the RNC showed a lack of understanding of the facility's policies, which required cleaning reusable items after use.
The facility failed to maintain a safe and sanitary environment in several resident rooms, with vent covers covered in dark debris resembling mold and a hanging ceiling rail posing injury risks. Staff interviews revealed a lack of communication and responsibility in addressing these issues, with the Maintenance Director ordering new vents only after being notified. The facility's Housekeeping Standards policy was not adhered to, placing residents at risk for infection and decreased quality of life.
A resident with multiple health conditions, including dementia and hemiplegia, was left in a soaked brief and bedding for about six hours without receiving necessary incontinence care. Despite the facility's policy requiring regular checks, the CNA responsible did not perform timely rounds, leaving the resident at risk for skin breakdown and infection. The facility's policy lacked specific guidelines on the frequency of incontinence checks.
A medication cart was found unlocked and unattended in a facility, with two residents nearby, one of whom was cognitively intact and on psychotropic medications. The ADON left the cart unsecured due to distraction, and the facility lacked a specific policy for medication cart security, as confirmed by the DON.
A facility failed to update a resident's care plan quarterly, as required. The resident, who was cognitively intact and had a history of stroke, cataracts, depression, and anxiety, had a care plan that had not been revised for several months. Interviews revealed that the DON was unfamiliar with the care plan update process, and the Administrator was unaware of the risks of not updating care plans.
Failure to Prepare Pureed Food to Required Consistency
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual resident needs during a lunch meal. Specifically, pureed rice pilaf was not prepared to a pudding-like consistency as required for residents on pureed diets. Observation of a sample tray revealed that the pureed rice contained chunks of rice grains and was not fully pureed. The dietary manager (DM) acknowledged that the rice should have been smoother and easier to swallow, but did not check the texture of the pureed food items, citing that she had just started working at the facility and assumed the staff member responsible for preparing the pureed foods was knowledgeable about the requirements. The staff member who prepared the pureed foods confirmed that she made the pureed rice and believed it became chunky due to the addition of thickener. She admitted that the rice was not pudding-like or smooth but served it regardless. Review of the facility's policy indicated that meals should be provided according to physician orders and the facility diet manual, but this was not followed for the pureed rice during the observed meal.
Incomplete Clinical Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who experienced a significant change in condition. On the date in question, the resident, a male with multiple complex diagnoses including Type 1 Diabetes, End Stage Renal Disease, and Congestive Heart Failure, was transferred to the hospital after experiencing hypoglycemia. Documentation in the clinical record was incomplete, as the times for five blood glucose monitoring tests, three medication administrations, and contacts with the nurse practitioner and emergency medical services were not recorded. Interviews with facility staff confirmed that it is required practice to document the date, time, drug, and dose when administering medications, and to record the timing of significant events in the medical record. Staff acknowledged that failure to document these details could result in confusion for subsequent shifts and potentially lead to medication errors. The nurse responsible for the resident's care on the day of the incident admitted to usually documenting at the end of the shift and was unable to explain the omission of documentation for that day. Review of the facility's policy on clinical documentation emphasized the importance of objective, chronological, and complete entries, including the time of care and services provided. The policy also outlined procedures for late entries and corrections, underscoring the expectation that all significant events and care provided should be documented promptly and accurately. The lack of complete documentation in this case was inconsistent with both facility policy and accepted professional standards.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via enteral feeding received appropriate treatment and services to prevent complications. Specifically, a nurse used a de-clogger tool to unclog a resident's g-tube without obtaining prior physician orders, despite the facility not training nurses on the use of such tools. The facility had de-clogger tools on-site, although they were not an approved method for de-clogging g-tubes, and the nurse did not follow the protocol of notifying the physician before using the tool. Additionally, the facility did not adhere to the physician's orders regarding the flushing of the resident's enteral feeding tube. The orders specified that the tube should be flushed with 100 ml of water every 2 hours, but observations revealed that the water flush rate was set at 200 ml every 4 hours. This discrepancy was identified by a nurse during her shift, who then adjusted the feeding pump to the correct settings. The failure to follow the physician's orders posed a risk of the g-tube clogging, which could lead to serious complications for the resident. The resident involved was an elderly male with multiple medical conditions, including cerebral artery issues, aphasia, tracheostomy status, gastrostomy status, dysphasia, respiratory failure, and renal failure. The resident was unable to answer questions during observations, and his care plan indicated a need for careful management of his feeding tube to prevent aspirations, weight loss, and dehydration. The facility's failure to follow proper procedures and physician orders for enteral feeding placed the resident at risk for serious harm.
Facility Lacks Full-Time Social Worker for Over 60 Days
Penalty
Summary
The facility, which is licensed for more than 120 beds, failed to employ a qualified social worker on a full-time basis since September 26, 2024. This deficiency was identified through interviews and record reviews, revealing that the facility had not had a full-time social worker since the previous one was terminated on September 25, 2024. The absence of a social worker was confirmed by a confidential resident group interview, where all ten residents in attendance stated that the facility had been without a social worker for months. The residents were informed that the facility was actively searching for a new social worker. Further investigation showed that the facility's HR department confirmed the lack of a social worker since the end of September and mentioned that a new hire had been made, but the individual had not yet started. The newly employed Administrator, who began on January 13, 2025, confirmed that the facility had been without a social worker for approximately 60 days. During this period, the Director of Nursing (DON), Medical Records, MDS Coordinators, and Assistant Directors of Nursing (ADONs) were addressing residents' social service needs. However, the Administrator acknowledged the necessity of a social worker to advocate for residents' rights, participate in care planning, and ensure psychosocial needs were met. The facility did not have a policy for social services in place.
Failure to Ensure Resident Privacy Due to Inadequate Curtains
Penalty
Summary
The facility failed to ensure full visual privacy for four residents due to inadequate privacy curtains in their rooms. Observations and interviews revealed that Resident #3 had a privacy curtain hanging by only four hangers, leaving her exposed during personal care. She expressed discomfort with the lack of privacy, especially during incontinent care. Resident #47 had no privacy curtain at the foot of his bed and had requested either a curtain or a room change for more privacy, but his request had not been addressed. Resident #61, who currently had no roommate, noted discomfort when he previously shared the room without a privacy curtain between the beds. Resident #46 also lacked a privacy curtain at the foot of the bed, and there was no track for hanging one. He had been in this situation since moving into the room. Interviews with staff, including the ADON, CNA, RN, and supervisors of housekeeping and maintenance, revealed a lack of awareness and responsibility for ensuring privacy curtains were in place and functional. The housekeeping staff was responsible for changing and cleaning the curtains, while maintenance was tasked with repairs, but there was no surplus of curtains to replace those being washed. The facility did not have a specific policy addressing resident privacy or privacy curtains, only a general Resident Rights policy stating the right to a clean, comfortable, home-like environment. The lack of a clear policy and communication among staff contributed to the deficiency, as evidenced by the unaddressed issues with privacy curtains in multiple residents' rooms.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living to a resident with severe cognitive impairment and physical limitations. The resident, an elderly female with diagnoses including myopathy, reflux, unsteadiness on feet, and failure to thrive, required extensive assistance for personal hygiene as indicated in her care plan. Despite this, observations revealed that her fingernails were uneven, jagged, and had a black substance underneath, which the resident expressed dissatisfaction with, stating that her nails often got caught in her bedding. Interviews with facility staff indicated that nail care was the responsibility of CNAs unless the resident had diabetes, in which case a nurse would perform the task. However, despite the resident's need for assistance, her fingernails remained untrimmed over consecutive days. The facility's nail care policy outlined specific procedures for nail care, but these were not followed, leading to the resident's unkempt nails and potential risk for infections or injuries.
Failure to Provide Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a right hand contracture, which is a permanent tightening of the muscles. The resident, who is an elderly male with a history of aphasia, hemiplegia, and memory problems, was observed without a contracture management device in place over several days. Interviews with staff revealed that the resident had a splint for his hand contracture, but it was not applied because it was likely in the laundry. Staff members, including a CNA, LVN, and the Occupational Therapist, were unaware of the resident's current use of the splint, and there was no physician's order for the splint or palm guard. The Occupational Therapist noted that the palm guard had not been located for about two weeks, and there was no clear documentation or order for its use. The facility's policy on splinting requires a physician's order and an Occupational Therapist evaluation, which were not in place for this resident. The absence of the splint or palm guard could lead to further tightening of the contracture, skin breakdown, and pain from stiffness, as noted by the ADON. The lack of consistent application of the contracture management device and the absence of a formal order contributed to the deficiency in care for the resident.
Failure to Ensure Physician Orders for Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as there were no physician orders for tracheostomy care, suction tubing, or an emergency trach kit. This deficiency was identified for a resident who was admitted with a tracheostomy and had a history of cerebral artery issues, aphasia, respiratory failure, and renal failure. The resident's care plan indicated the need for tracheostomy care, but the necessary physician orders were missing, which could lead to inadequate care. Observations revealed that the resident had a tracheostomy and feeding tube, and an emergency kit was present at the bedside. However, interviews with nursing staff indicated that the admitting nurse failed to input the necessary orders into the system, and the orders might have been deleted after the resident's hospital visit. The nurse assigned to the resident was unaware of the missing orders and continued to provide care without them, which could give the impression that care was not being provided. The facility's policies required verification of physician orders for tracheostomy care, but these were not followed. The ADON and RNC were unaware of the missing orders and emphasized the importance of obtaining and entering physician orders into the system. The lack of physician orders could potentially lead to the resident not receiving the necessary tracheostomy care, as outlined in the facility's policies.
Failure to Prepare Pureed Food Consistently
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for residents requiring pureed diets. During a lunch meal, the facility did not prepare and serve pureed mashed potatoes with the required pudding consistency. Instead, the mashed potatoes contained chunks and were not fully mashed, which was observed during a test tray review. The Dietary Manager used a hand whisk instead of a blender to puree the mashed potatoes and did not verify the consistency before serving. The Dietary Manager acknowledged that the mashed potatoes were not smooth and contained lumps, which could pose a choking risk to residents. The facility's Pureed Recipe Book General Guidelines policy specifies that pureed foods should have a moist mashed potato consistency to prevent swallowing difficulties or aspiration. The Dietary Manager admitted to normally overseeing staff in preparing pureed meals but was directly involved in preparing the mashed potatoes on this occasion.
Inadequate Sanitization of Medical Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA D) who did not sanitize a reusable blood pressure cuff between uses on two residents. Resident #5, a male with kidney disease, diabetes, high blood pressure, and heart failure, required assistance with all activities of daily living (ADLs) and had a BIMS score indicating he was cognitively intact. Resident #60, a male with complete paralysis and mild cognitive impairment, also required total assistance with ADLs and was cognitively intact. Observations revealed that MA D used the same blood pressure cuff on both residents without sanitizing it between uses, which could expose residents to infections. Interviews with MA D and the Registered Nurse Coordinator (RNC) highlighted a lack of awareness and understanding of the facility's infection control policies. MA D admitted to forgetting to use sanitizing cloths, despite having them available, and acknowledged the risk of spreading infections. The RNC incorrectly stated that reusable medical equipment only needed to be sanitized if visibly soiled and was unable to articulate the risks of not sanitizing equipment between uses. The facility's policy required cleaning and storing reusable items after use, which was not followed in this instance.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in four of the five rooms reviewed for environmental conditions. Observations revealed that the vent covers in Rooms 221, 225, 229, and 231 were covered with dark debris, resembling mold, dust, and dirt. The vents appeared to have thick black dust and debris both inside and outside. Additionally, a silver ceiling rail was found hanging from the ceiling in one of the rooms, posing a risk of injury to residents and staff. Interviews with staff members, including a housekeeper, a CNA, an LVN, and the Maintenance Director, indicated a lack of communication and responsibility in addressing the environmental issues. The housekeeper was aware of the dirty vents but had not reported them to the Maintenance Director, assuming he would have checked all vents. The CNA acknowledged the potential health risks posed by the dirty vents but had not reported them either. The LVN was informed of the issues but had not yet observed the vents herself. The Maintenance Director stated that he was responsible for cleaning the vents and had ordered new ones after being notified of the problem. The facility's Administrator acknowledged the deficiencies and stated that staff conducting Angel Rounds should have reported the issues. The facility's Housekeeping Standards policy emphasized the importance of maintaining a clean and sanitary environment to prevent the spread of disease and infection. However, the lack of adherence to these standards resulted in the identified deficiencies, placing residents at risk for infection and decreased quality of life.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, a female with a history of stroke, hypertension, peripheral artery disease, hemiplegia, dementia, seizure disorder, and anxiety disorder, was found to be frequently incontinent of bowel and bladder. Despite requiring partial/moderate assistance with toileting, showering, bathing, and personal hygiene, the resident was left in a soaked brief and bedding for approximately six hours without being changed. Observations and interviews revealed that the resident had been in bed since the start of the 6:00 AM-2:00 PM shift and had not received incontinence care until 11:50 AM. The resident expressed discomfort and dissatisfaction with being left wet. CNA A, responsible for the resident's care during this shift, admitted to not checking on the resident for incontinence care since around 10:00 AM, as the resident was sleeping. The CNA acknowledged the importance of ensuring residents are clean and dry to prevent skin damage and irritation. The facility's Director of Nursing (DON) confirmed that CNAs are responsible for conducting rounds every two hours to ensure residents are clean and dry, and that nurses should also check on residents. The facility's incontinence care policy outlined procedures for cleaning after an incontinence episode but did not specify the frequency of checks. The failure to provide timely incontinence care placed the resident at risk for skin breakdown, infection, and pressure sores.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by State and Federal laws. During an observation on the 100 halls, a medication cart was found unlocked and unattended. This occurred on 04/30/24 at 9:20 AM, with residents in close proximity to the unsecured cart. Resident #3 was sitting next to the cart, and Resident #1 was observed moving independently in his wheelchair near the cart multiple times. The medication cart remained unsupervised until 9:34 AM when another employee locked it, indicating that ADON A was responsible for the cart. Resident #1, a male with a history of cerebral infarction, depression, and anxiety, was cognitively intact with a BIMS score of 15. He required supervision for activities of daily living and was on psychotropic medications. Despite his cognitive status, he was observed near the unlocked medication cart, which posed a risk given his behavioral history of physical and verbal aggression. Resident #2, a female with severe cognitive impairment and dementia, was also near the cart, asleep in her wheelchair, and moving closer to it intermittently. Interviews with staff revealed that ADON A left the cart unlocked due to being distracted by another task. Both the DON and the Administrator acknowledged the expectation that medication carts should be locked when unattended to prevent unauthorized access. However, the facility lacked a specific medication cart security policy, as confirmed by the DON. This oversight in securing medication carts could potentially lead to residents accessing medications, posing risks of overdosing or adverse reactions.
Failure to Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for one resident, a cognitively intact male with a history of cerebral infarction, cataracts, depression, and anxiety. The resident's care plan, dated several months prior, had not been updated as required, despite the resident's ongoing need for supervision with activities of daily living and the use of psychotropic medications for depression and anxiety. Interviews with facility staff revealed a lack of familiarity and training regarding the care plan update process. The Director of Nursing (DON), who had been in the position for two weeks, acknowledged that the care plans should have been updated quarterly and was not aware of the facility's process for updating them. The facility's Administrator was aware of a backlog of care plans that had not been updated by previous nursing staff and had hired new nurse managers to address the issue. However, the Administrator was unaware of the risks associated with not updating care plans.
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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