Willow Ridge Wellness & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 8001 Western Hills Blvd, Fort Worth, Texas 76108
- CMS Provider Number
- 455416
- Inspections on file
- 59
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Willow Ridge Wellness & Rehabilitation during CMS and state inspections, most recent first.
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.
A resident with a history of stroke sequelae, CHF, glaucoma, and type 2 DM, who was moderately cognitively impaired and dependent on staff for ADLs and bed mobility, was found lying in bed directly on the sealed plastic packaging of a new mattress, with exposed back and bare calves in contact with the plastic. The resident reported leg pain and was unaware how long she had been on the plastic. Nursing staff, including CNAs and an RN, acknowledged they had seen or worked with the resident on the new mattress but either did not recognize or did not verify that the surface was packaging rather than a specialized mattress, and did not ensure removal of the plastic or proper bed linens. Leadership staff later confirmed that facility expectations and policy required removal of mattress packaging and provision of a properly made bed, which had not occurred in this case.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, increasing the risk of resident accidents.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Surveyors observed that several air duct registers in multiple halls were covered with black spots, rust, and peeling paint, with one not securely fitted in the ceiling. Housekeeping and maintenance staff confirmed their respective responsibilities for cleaning and replacing the registers, but issues were not proactively identified or addressed. The DON acknowledged that air duct registers had not been specifically checked during room rounds, despite facility policy requiring a clean and homelike environment.
A staff LVN was observed assisting a resident with their meal while talking on the phone, which the LVN later acknowledged was inappropriate and disrespectful. The DON confirmed that staff are expected to give residents their full attention during meal assistance and that facility policy prohibits phone use in patient care areas to ensure residents are treated with dignity and respect.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, leading to incomplete planning and documentation of care.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A CNA documented care for a resident with severe cognitive impairment using another CNA's EHR log-in credentials, resulting in inaccurate medical records. Staff interviews confirmed that sharing or using another person's log-in was not permitted, and the DON stated this practice created false documentation. The Administrator acknowledged the absence of a specific policy on this issue.
Two residents with severe cognitive impairment and histories of aggressive behavior were involved in a physical altercation that resulted in serious injury, including a suspected spinal fracture and facial hematoma. At the time, only one CNA was present on the unit, as the nurse had left to obtain medication, leaving the area unsupervised. Previous altercations between these residents had been documented, and staff reported that the usual staffing was insufficient to provide adequate supervision for residents with dementia and behavioral issues. The incident was initially reported as an unwitnessed fall, and there was a delay in recognizing the extent of the injuries.
Two residents with severe cognitive impairment and histories of aggression and wandering were left inadequately supervised when only one CNA was present on the unit, as the nurse had left to obtain medication. This lapse in supervision allowed a physical altercation to occur between the residents, resulting in both falling and one sustaining a suspected spinal fracture and a black eye. Staff and family interviews confirmed that both residents had a history of aggressive interactions, and care plans had identified the need for separation and supervision, but these interventions were not effectively implemented.
A resident with multiple chronic conditions and recent surgery was deprived of prescribed Norco and morphine when the ADON removed over 150 tablets and a bottle of morphine from the med cart without authorization, resulting in unrelieved pain for several days. Staff interviews revealed the ADON misrepresented facility policy and removed the medications without proper discontinuation or verification.
A CMA physically and verbally abused a resident with dementia and other behavioral health diagnoses by slapping a glass of water from her hand after the resident called her a derogatory name, resulting in the resident crying and experiencing psychosocial harm. The incident was witnessed by staff, confirmed by the CMA, and found to be in violation of the facility's abuse prevention policy.
A resident with multiple health issues, including quadriplegia and obesity, was admitted with a stage II pressure injury. The facility failed to promptly obtain and implement wound care orders, leading to a delay in treatment. This resulted in the injury progressing to an unstageable wound. Staff interviews revealed that the wound care nurse's resignation contributed to the delay, and the facility's policy for immediate assessment and documentation was not followed.
A facility failed to notify a resident's representative of a significant change in the resident's mental status and treatment. The resident, diagnosed with dementia and other conditions, was placed on antipsychotic medication without informing the medical power of attorney. Despite the facility's policy to notify representatives of such changes, documentation showed the resident signed consent forms independently, contrary to expectations.
A facility failed to obtain immediate physician orders for a resident admitted with a pressure wound. The resident, with multiple health issues including a stage II ulcer, did not receive timely treatment due to a lack of physician notification. The ADON did not document contacting the doctor, and the physician was only informed two weeks later, by which time the wound prognosis had worsened. The DON expected immediate notification, but this did not occur, leading to a delay in treatment.
The facility failed to provide three residents with access to functioning call lights, essential for requesting assistance. Observations showed that rooms lacked call lights, with only a switch box present without activation strings. Staff interviews revealed a lack of awareness about the importance of call lights, with some believing residents were self-sufficient. The administration acknowledged the risk and emphasized the policy requiring reasonable accommodation for residents' needs, including call light access.
The facility did not comply with food service safety standards, as items in the walk-in refrigerator were found unlabeled and improperly stored, risking food-borne illness. Staff interviews revealed that the Admission Director, temporarily assisting in the kitchen, had limited time to ensure safe practices, while the DON and Administrator stressed the importance of proper food labeling and sealing. The facility's 2018 policy requires all refrigerated foods to be dated, labeled, and sealed, which was not adhered to.
The facility failed to ensure safe and sanitary storage of foods brought by family and visitors in the Suites Medication Room refrigerator. An observation revealed unlabeled and undated food items, including drinks and sandwiches, which were not clearly identified as belonging to residents or staff. The ADON and DON acknowledged the risk of residents consuming expired or contaminated food, contrary to facility policies requiring labeling and dating of all stored food.
The facility failed to maintain proper infection control practices, as observed in the kitchen where a non-functional soap dispenser led staff to use soap from a bag in the sink. Additionally, a CNA did not perform hand hygiene before assisting a resident with eating, and an RN failed to sanitize hands between serving meals to multiple residents. These actions were contrary to the facility's infection control policies, posing a risk of cross-contamination and infection spread.
The facility failed to maintain an effective pest control program, leading to the presence of gnats and flies in the kitchen. Observations revealed pests near food preparation areas, with staff attempting to prevent flies from landing on food. Interviews confirmed that the backdoor being left open during deliveries allowed pests to enter, and pest control services were requested to address the issue.
A resident with multiple medical conditions, including quadriplegia, was observed without a privacy cover on his catheter bag in both the therapy room and entrance area, compromising his dignity. Facility staff acknowledged the importance of privacy covers, as per the facility's policy, but failed to ensure its use during the observations.
A resident's care plan was not updated to reflect current dietary orders, despite changes in nutritional recommendations. The resident, with multiple health conditions, was observed consuming a regular diet, while the care plan still indicated a pureed diet. Facility staff interviews revealed a lack of clarity on responsibility for updating care plans, leading to conflicting information. The facility's policy required care plans to be revised as conditions changed, but this was not followed.
A resident with multiple medical conditions, including dementia and Parkinsonism, fell during a transfer due to inadequate supervision and lack of proper equipment use by CNAs. Despite the care plan requiring a mechanical lift and two staff members for transfers, the resident was assisted without a gait belt or lift, resulting in a fall. The incident highlighted inconsistencies in staff adherence to the care plan and facility policies on safe lifting.
An LVN left a medication cart unlocked and unattended in a busy hallway, violating facility policy and potentially allowing unauthorized access to medications. Interviews with the DON and ADM confirmed the expectation that medication carts be locked when not in use to prevent harm to residents.
A facility failed to immediately inform a resident's physician and notify the resident's representative about changes in the resident's condition, leading to delayed wound care and treatment. The resident, who had severe cognitive impairment, returned from the hospital with two small open wounds. Despite the family's request to use a specific cream, the facility did not consult the MD or Wound Care Doctor, resulting in the deterioration of the resident's wounds and eventual hospitalization for surgery.
A facility failed to ensure timely consultation with the MD or Wound Care Doctor for a resident with pressure ulcers, leading to the worsening of the resident's condition and requiring surgical intervention. The resident had severe cognitive impairment and was always incontinent, and the facility delayed obtaining consent and proper treatment orders, resulting in significant deterioration of the wounds.
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.
Resident Left Lying Directly on Plastic Mattress Packaging
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by allowing a resident to lie directly on the sealed plastic packaging of a new mattress. The resident was an elderly female with a history of cerebral infarction sequelae, glaucoma, congestive heart failure, and type 2 diabetes. Her MDS showed moderate cognitive impairment (BIMS score of 8), total incontinence of bowel and bladder, and dependence on staff for toileting, showers, and transfers. Her care plan identified an ADL self-care deficit related to debility and required extensive assistance by two staff for bed mobility and weekly skin inspections. A recent reentry skin assessment documented only bruising from an IV and no pressure wounds. On the survey date, observation revealed the resident lying in bed on top of the protective plastic packaging of a brand-new mattress, with her exposed back and bare calves in direct contact with the plastic. The resident reported hearing a sound when she moved and stated she did not know how long she had been on the plastic but that her legs were hurting, then requested assistance to move her legs. When RN A entered the room and repositioned the resident’s legs, she observed that the resident’s bare calves had been lying flat on the plastic. RN A stated she did not know who had placed the resident on the new mattress without removing the plastic or how long the resident had been on it, and acknowledged that the resident’s skin was directly on the plastic and that this was not a homelike environment. Multiple staff interviews confirmed that the plastic packaging had not been removed prior to the resident being placed on the mattress and that expected practices were not followed. CNA C reported the resident had been back from the hospital for about a week and stated she did not know why the person who put the resident on the new mattress did not remove the packaging or extend the bottom sheet, noting that the material under the resident was the actual packaging, not a specialized mattress surface. CNA D stated he had been assigned to the resident, noticed at the start of his shift that the mattress still had plastic packaging, and assumed it might be a specialized mattress from a vendor and did not verify this with a nurse. The MDS nurse, DON, and Administrator each stated that the expectation was that plastic packaging would be removed and the bed made with appropriate linens before a resident was placed in bed, and acknowledged that in this case the resident had been left lying directly on the non-breathable plastic packaging of the new mattress.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Maintain Clean and Homelike Environment Due to Dirty Air Duct Registers
Penalty
Summary
The facility failed to provide a clean and homelike environment in three of five residential halls, specifically Halls 200, 300, and 400. Observations revealed that six ceiling air duct registers across these halls were covered with small black spots, rust, and peeling paint chips, and one register was not securely fitted into the ceiling tile. These conditions were directly observed by surveyors during their walkthroughs. Interviews with the maintenance manager and housekeeping manager confirmed that housekeeping was responsible for cleaning the air duct registers, while maintenance was responsible for replacing them. However, both managers indicated that staff must submit a work order for maintenance to address issues, and there was a lack of proactive monitoring of the air duct registers' condition. The Director of Nursing (DON) stated that room rounds were conducted to check room conditions but admitted that air duct registers had not been specifically checked. Upon being shown the condition of one of the affected air duct registers, the DON acknowledged the importance of clean air duct registers for maintaining a homelike and healthy environment. Review of the facility's policy on maintaining a homelike environment confirmed the expectation for a clean, sanitary, and orderly setting, which was not met in this instance.
Staff Use of Phone During Resident Meal Assistance Violates Resident Dignity
Penalty
Summary
A staff member, identified as an LVN, was observed assisting a resident with their meal while simultaneously talking on the phone. The LVN admitted during an interview that he was on the phone with a doctor at the time and acknowledged that it was inappropriate to be on the phone while assisting residents with meals. He explained that this behavior could distract from the resident, potentially leading to unsafe situations such as the resident picking up something they should not put in their mouth, and described the action as disrespectful. The Director of Nursing (DON) confirmed in an interview that staff are expected to sit next to residents, assist one resident at a time, and ensure proper hand hygiene before assisting each resident. The DON stated that being on the phone while assisting a resident is not acceptable, citing concerns about lack of attention, potential HIPAA violations, and unprofessionalism. Facility policy reviewed indicated that all residents are to be treated with kindness, respect, and dignity, and that being on the phone in the patient care area is not permitted.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Inaccurate EHR Documentation Due to Shared Log-in Credentials
Penalty
Summary
The facility failed to maintain accurate medical records for a resident when a CNA documented care in the electronic health record (EHR) using another CNA's log-in credentials. Specifically, on 06/06/25, CNA A provided care to a resident with severe cognitive impairment and total dependence for activities of daily living, but documented the care under CNA B's credentials. CNA B confirmed she had not worked with the resident that day and had been assigned to another unit. CNA A admitted to using CNA B's log-in because her own credentials frequently malfunctioned, and she had reported the issue without resolution. CNA B stated she may not have signed out of the computer, allowing CNA A to chart under her name. Multiple staff interviews, including CNAs, RNs, the ADON, DON, and the Administrator, confirmed that it was not permitted to use or share log-in credentials for documentation purposes. The DON stated that log-in issues could be resolved quickly and that documenting under another person's credentials constituted false documentation. The Administrator acknowledged there was no specific policy addressing the use of other staff members' log-ins, but considered it common sense not to do so.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents from abuse when both individuals, each with severe cognitive impairment and a history of aggressive behaviors, became involved in a physical altercation. Video footage showed one resident entering the other's room, followed by a struggle in the hallway where both residents fell to the ground. One resident sustained a suspected T4 vertebral fracture and a right periorbital hematoma, while the other had visible bruising. At the time of the incident, only one CNA was present on the unit, as the nurse had left to obtain medication, leaving the unit unsupervised for approximately 15 to 30 minutes. Both residents had documented histories of wandering, physical aggression, and behavioral issues, with care plans indicating the need for interventions to protect the safety of others. Staff interviews revealed that altercations between these two residents had occurred previously, and staff had previously separated them to prevent harm. Despite these known risks, the staffing pattern on the locked memory care unit was typically one nurse and one CNA, and staff reported that this was insufficient to meet the supervision needs of residents with dementia and behavioral challenges. On the evening of the incident, the lack of adequate supervision allowed the altercation to escalate without immediate intervention. Documentation and interviews indicated that the incident was initially reported as an unwitnessed fall, and there was a delay in recognizing and responding to the severity of the injuries. Family members of the residents expressed concerns about the lack of supervision and communication from the facility. The facility's own policies required prompt reporting, investigation, and intervention in cases of resident-to-resident altercations, but these were not effectively implemented, resulting in significant harm to one resident and placing others at risk.
Failure to Provide Adequate Supervision Resulting in Resident Altercation and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for two residents with severe cognitive impairment and behavioral issues. Both residents had documented histories of wandering, physical aggression, and prior altercations. On the day of the incident, video footage showed one resident entering another's room, leading to a physical altercation in the hallway. The altercation escalated, resulting in both residents falling to the ground, with one sustaining a suspected T4 vertebral fracture and a right periorbital hematoma. At the time, only one CNA was present on the unit, as the nurse had left to obtain medication, leaving the unit unsupervised for 15 to 30 minutes. Interviews with staff revealed that the unit was typically staffed with one nurse and one CNA, and there were times when only one staff member was present, especially when the other left for breaks or other duties. Staff and family members reported that both residents had a history of aggressive behaviors toward each other and required separation to ensure safety. Despite these known risks, the facility did not provide sufficient supervision or implement effective interventions to prevent resident-to-resident altercations. Documentation also indicated that previous altercations had occurred between these residents, but no injuries had been reported until this incident. The care plans for both residents identified their behavioral risks and included interventions such as removing them from situations and diverting their attention. However, these interventions were not effectively implemented at the time of the incident. The lack of adequate supervision and failure to follow established care plan interventions directly contributed to the altercation and resulting injuries. The facility's staffing patterns and supervision practices were insufficient to address the needs of residents with known behavioral risks, leading to a serious incident that resulted in significant injury.
Misappropriation of Controlled Medications by ADON
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of their controlled medications, specifically Norco (hydrocodone/acetaminophen) and morphine. The Assistant Director of Nursing (ADON) removed over 150 tablets of Norco and a bottle of morphine from the medication cart without proper authorization or following established procedures. The ADON claimed to be conducting a narcotics audit and told staff that medications not used for 90 days or discontinued would be removed, but there was no evidence that these medications were discontinued or that the resident was not returning. The medications were never recovered. The resident affected had a history of dementia, diabetes, end-stage renal disease, chronic pain due to neuropathy from a below-knee amputation, and had recently undergone a toe amputation. Upon returning from the hospital, the resident was unable to receive his prescribed Norco for pain management because the medication had been removed from the cart. Instead, he was given Tylenol with codeine, which he reported did not adequately relieve his pain. Documentation showed that the resident experienced pain levels of 7-8 for two to three days following his return, which would have been managed with the missing Norco. Multiple staff interviews confirmed that the ADON removed the narcotic medication cards from the cart, citing incorrect facility policy and without proper verification or discontinuation orders. Staff did not initially question the ADON's actions due to her management position. The facility's prior policy allowed nurses to discard empty narcotic cards themselves, but the removal of full cards with active orders was not permitted. The incident was discovered when staff noticed the missing medication and reported it to the Director of Nursing, who confirmed that the medications had not been discontinued or destroyed according to protocol.
Staff-to-Resident Abuse: Physical and Verbal Aggression by CMA
Penalty
Summary
A certified medication aide (CMA) engaged in staff-to-resident abuse involving a female resident with a primary diagnosis of dementia and secondary diagnoses including parkinsonism, epilepsy, and bipolar disorder. The resident was cognitively intact according to her most recent assessment and had no documented behavioral symptoms directed toward others. The incident occurred when the resident, while holding a glass of water, called the CMA a derogatory name. In response, the CMA threatened the resident and then slapped the glass of water out of her hand, causing the resident to cry and experience psychosocial harm. Multiple staff members witnessed or were informed of the incident. A family nurse practitioner (FNP) overheard the escalating exchange and the subsequent slapping sound, after which the resident began to cry and requested that staff call the police. Another nurse (RN) confirmed witnessing the CMA slap the glass of water from the resident's hand, resulting in water spilling on the resident and the floor. The resident was emotionally upset but did not sustain physical injuries. The CMA admitted to the action during an interview with the facility administrator, stating it was in response to being called a derogatory name by the resident. The facility's abuse policy strictly prohibits any form of abuse, including physical and mental abuse, and defines abuse as the willful infliction of injury or punishment resulting in physical harm, pain, or mental anguish. The incident was confirmed as abuse by the facility's investigation, and the CMA was terminated. The report documents that the resident was emotionally distressed following the incident, and staff interviews confirmed that the expected standard of redirecting residents and not reacting physically was not followed in this case.
Delayed Wound Care Orders Lead to Deterioration of Resident's Pressure Injury
Penalty
Summary
The facility failed to provide timely and appropriate wound care for a resident who was admitted with a stage II pressure injury. Upon admission, the resident's pressure injury was not immediately addressed with appropriate wound care orders, which were only obtained several days later. The delay in entering these orders into the Electronic Health Record (EHR) system further postponed the initiation of necessary treatment, contributing to the deterioration of the resident's condition. The resident, who had multiple health issues including quadriplegia, obesity, and diabetes, was initially assessed with a stage II pressure injury. However, due to delays in implementing the wound care physician's orders, the injury progressed to an unstageable wound. The facility's failure to promptly enter and execute the physician's orders resulted in a significant delay in treatment, which was noted by both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) as a risk for delayed wound healing. Interviews with facility staff revealed that the wound care nurse had resigned, leading to a lack of continuity in wound care management. The ADON, who was responsible for entering the orders, failed to do so in a timely manner, and the DON acknowledged that this delay could have contributed to the resident's wound deterioration. The facility's policy required immediate assessment and documentation of pressure ulcers, but this protocol was not followed, resulting in a deficiency in care for the resident.
Failure to Notify Resident's Representative of Significant Change
Penalty
Summary
The facility failed to immediately notify the representative of a resident when there was a significant change in the resident's mental status. This deficiency was identified for a resident who had a medical power of attorney assigned to a family member. Despite the resident's cognitive decline due to dementia, the facility did not inform the family member or representative about the resident's diagnosis of Schizoaffective Disorder or the initiation of treatment with the antipsychotic medication Risperidone. The resident, an elderly female with a primary diagnosis of dementia, was also diagnosed with several other conditions, including diabetes mellitus, auditory hallucinations, cerebral infarction, and schizoaffective disorder. Despite having a BIMS score indicating cognitive intactness, the resident's dementia was severe enough to impair her ability to make competent decisions regarding her treatment. The facility's records showed that the resident signed consent forms for antipsychotic medication without the involvement of her medical power of attorney, which was against the facility's policy of notifying representatives of significant changes in diagnosis or treatment. Interviews with the Director of Nursing (DON) revealed that the facility expected to notify a resident's representative or family whenever there was a change in diagnosis or treatment. However, the facility failed to do so in this case, as evidenced by the lack of documentation indicating that the resident's representative was informed of the changes. The DON acknowledged that the resident had behavior problems and that the facility had the resident sign for consent due to her being considered her own responsible party, despite the presence of a medical power of attorney.
Failure to Obtain Immediate Physician Orders for Pressure Wound
Penalty
Summary
The facility failed to obtain physician orders for immediate care when a resident was admitted with a pressure wound. Upon admission, the resident, a male with multiple diagnoses including hypertension, neurogenic bladder, quadriplegia, diabetes, obesity, and a stage II ulcer of the right buttocks, did not have physician orders for the treatment of his pressure wound. The resident's care plan and hospital records indicated the presence of a pressure injury, but there was no documentation of physician notification or orders for treatment until two weeks after admission. Interviews and record reviews revealed that the nursing staff did not notify the physician about the resident's pressure wound in a timely manner. The Assistant Director of Nursing (ADON) conducted a skin observation but did not document contacting the doctor. The physician was first made aware of the wound two weeks after admission, by which time the prognosis of the wound had worsened. The Director of Nursing (DON) expected the admitting nurse to contact the doctor immediately upon discovering the wound, but this did not occur, leading to a delay in treatment and a decline in the resident's health.
Deficiency in Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that three residents had access to functioning call lights, which are essential for requesting assistance. Observations revealed that the rooms of these residents lacked call lights, with only a switch box present that was not equipped with a string to activate the call light. This deficiency was noted during a survey, where it was found that the call light system was outdated and not properly maintained, leading to the absence of necessary cords for activation. Interviews with staff members, including a CNA and an LVN, indicated a lack of awareness regarding the importance of call lights for residents. The CNA mentioned that most residents did not use call lights as they were self-sufficient, while the LVN acknowledged the right of residents to have call lights but noted that the cords were removed due to safety concerns. The maintenance supervisor confirmed that the call light system was old and that strings were removed by residents, but did not recognize the risk posed by the absence of call lights. The facility's administration acknowledged the issue, stating that it was the responsibility of staff to report broken equipment. The ADM recognized the risk to residents of not having call lights, especially during moments of clarity when they might need assistance. The facility's policy emphasized the right of residents to have reasonable accommodation for their needs, which includes access to call lights, highlighting the deficiency in meeting this standard.
Failure to Adhere to Food Storage Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. On the specified date, items in the walk-in refrigerator were found without labels or use-by dates, including a large Ziplock bag containing cheese, another with a sandwich, chips, packaged crackers, and a personal packet of mayonnaise, and a third with cooked bacon. Additionally, open packaging was noted, such as an uncovered box of lunch meat and a box of 24 count eggs with 18 eggs remaining. These observations indicate a lack of proper food storage practices, which could lead to food-borne illness and contamination. Interviews conducted with facility staff revealed further insights into the deficiency. The Admission Director, who had been assisting in the kitchen due to the recent departure of the dietary manager, acknowledged his limited time in the kitchen and mentioned reminding dietary staff about safe storage practices. The DON emphasized the importance of sealing food to prevent cross-contamination, while the Administrator highlighted the necessity of labeling food to ensure it is not expired and safe for consumption. The facility's policy on food storage, dated 2018, mandates that all refrigerated foods be dated, labeled, and tightly sealed, which was not followed in this instance.
Improper Food Storage in Medication Room Refrigerator
Penalty
Summary
The facility failed to ensure the safe and sanitary storage, handling, and consumption of foods brought to residents by family and other visitors. During an observation and interview with the Assistant Director of Nursing (ADON), it was revealed that the refrigerator in the Suites Medication Room contained various food items that were not labeled with residents' names or expiration dates. The refrigerator held a mix of items, including a box of thickened water, a 2-liter coke bottle, a gallon pitcher with an undated red drink, a half sandwich in an open bag, and other food items. The ADON was unsure whether the food belonged to staff or residents and acknowledged that the nursing staff was responsible for cleaning the refrigerator and ensuring food was labeled and up-to-date. The Director of Nursing (DON) was unaware of the refrigerator's status and acknowledged the risk of residents consuming expired or contaminated food. The facility's policy on food safety required that all food be covered, labeled with the resident's name, and dated, with a recommended use-by date of three days after preparation or purchase. Additionally, the policy on cleaning and sanitation of refrigerators stated that only residents' food should be stored, and all food should be labeled, dated, and covered. The failure to adhere to these policies placed residents at risk for food-borne illness.
Infection Control Deficiencies in Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations and interviews. The designated handwashing sink in the facility kitchen was found to have a non-functional soap dispenser, leading Dietary Aide A to use soap from a bag placed in the sink, which was not in compliance with infection control standards. The sink also contained food residue, and the soap dispenser was empty, which was confirmed by interviews with staff, including the Admissions Director and the Director of Nursing (DON), who acknowledged the risk of cross-contamination. Additionally, CNA A did not perform hand hygiene before assisting a resident with eating, directly handling the resident's food with bare hands. This resident, a male with multiple health conditions including dementia, Parkinsonism, and end-stage renal disease, required substantial assistance with eating. The failure to sanitize hands and the direct contact with the resident's food posed a risk of spreading germs and infections, as noted in interviews with various staff members who emphasized the importance of hand hygiene. Furthermore, RN F was observed serving meals in the dining room without performing hand hygiene between contacts with multiple residents. This practice was contrary to the facility's policy on hand hygiene, which requires sanitizing hands before and after resident interactions. Interviews with staff, including the Infection Preventionist and the Administrator, reiterated the expectation for staff to sanitize hands between resident interactions to prevent the spread of infections. The facility's policies on hand hygiene and infection control were not adhered to, leading to potential risks for all residents.
Pest Control Deficiency in Kitchen Area
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and flies in the kitchen area. Observations on two consecutive days revealed 4-5 gnats flying from a trash can near the handwashing sink and 4-5 flies around the stove, three-compartment sink, and juice dispenser. Additionally, the kitchen backdoor, used for taking out trash and receiving deliveries, was found partially open, allowing pests to enter. Staff members were observed waving their arms to prevent flies from landing on food, and a fly was seen landing on a meal tray. Interviews with facility staff, including a Dietary Aide, Admissions Director, and Maintenance Director, confirmed the issue with flies and gnats in the kitchen. The Dietary Aide noted that the backdoor being left open during deliveries allowed flies to enter, and gnats were often found around dish machines and drains. The Admissions Director acknowledged the unsanitary conditions of having flies around food preparation and serving areas. The Maintenance Director was unaware of the issue until informed and stated that pest control would be contacted to treat the affected areas. A record review indicated that the facility requested emergency pest control services to address the fly infestation, with treatment applied in the kitchen where the highest concentrations of flies and gnats were observed.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure that a resident's dignity and privacy were maintained, as evidenced by the lack of a privacy cover for the resident's indwelling catheter. The resident, who was cognitively intact and had multiple medical conditions including quadriplegia and a pressure ulcer, was observed in the physical therapy room and later by the facility's entrance with his catheter bag exposed. This exposure occurred despite the facility's policy to promote privacy and dignity, and the resident's care plan which included maintaining dignity and cleanliness. Interviews with facility staff, including an LVN and the DON, confirmed that the catheter bag should have been covered with a dark privacy cover to promote dignity. The LVN noted that the resident had a privacy cover earlier in the shift, but did not acknowledge the risk of not having one. The DON and ADM both emphasized the importance of privacy covers for catheter bags to protect residents' dignity, aligning with the facility's policy on resident rights.
Failure to Update Resident Care Plan with Current Dietary Orders
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by an interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for one resident who was reviewed for care plans. The resident, a male with multiple diagnoses including unspecified dementia, Parkinsonism, type 2 diabetes mellitus, end-stage renal disease, and anxiety disorder, had a care plan that did not reflect his prescribed diet of regular texture, regular consistency, and double protein portions. The resident's nutritional risk assessments indicated changes in dietary recommendations over time, including the addition of double protein portions and specific supplements. However, the care plan, initiated earlier in the year, continued to state a pureed diet with nectar thick liquids, which was not updated to reflect the resident's current dietary orders. Observations revealed that the resident was consuming a regular diet, and interviews with staff indicated a lack of clarity and responsibility regarding who should update the care plan. The registered dietitian and MDS nurse both acknowledged the discrepancy between the care plan and the actual diet orders. Interviews with facility staff, including the RD, MDS nurse, DON, and Administrator, revealed that care plans were expected to be updated when new orders were given, but this was not consistently done. The MDS nurse and DON stated that care plans could be updated by anyone in nursing, but the process was not clearly followed, leading to conflicting information in the resident's care plan. The facility's policy required comprehensive, person-centered care plans to be developed and revised as residents' conditions changed, but this was not adhered to in the case of the resident in question.
Failure to Provide Adequate Transfer Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment for Resident #13, who was not provided with adequate supervision and assistance devices during a transfer, leading to a fall. Resident #13, a male with multiple medical conditions including unspecified dementia, Parkinsonism, and end-stage renal disease, required extensive assistance for transfers, as indicated in his care plan. The care plan specified the use of a mechanical lift with two staff members for transfers on dialysis days or when the resident felt weak. However, on the day of the incident, CNAs A and C attempted to transfer the resident from his wheelchair to his bed without using a gait belt or mechanical lift, resulting in the resident falling to his knees. The incident was captured on camera, showing the CNAs assisting the resident without the necessary equipment, leading to the fall. Interviews with the resident and his family confirmed that the staff did not consistently use the mechanical lift, and sometimes only one person assisted with transfers. The resident expressed that he could not hold his own weight during the transfer, which led to his knees buckling and the subsequent fall. The ADON was called to assess the resident after the fall, and it was noted that the resident did not sustain any injuries. Interviews with facility staff revealed inconsistencies in the understanding and implementation of the resident's care plan regarding transfers. The ADON admitted to not being familiar with the care plan specifics, and CNAs reported varying levels of assistance provided to the resident, depending on his condition. The facility's policies on safe lifting and movement of residents were not adhered to, as manual lifting was used instead of the required mechanical devices, compromising the resident's safety.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. During an observation, it was noted that a Licensed Vocational Nurse (LVN) left a medication cart unlocked and unattended in the South Suites hallway. The cart was positioned against the wall by room twenty-five, and the LVN walked away from it to attend to room nineteen, leaving it unsecured for approximately five minutes. This lapse in security occurred in a busy hallway where staff were passing breakfast trays, increasing the risk of unauthorized access to the medications. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that the facility's policy required medication carts to be locked when not in use. Both expressed concerns that leaving medications unsecured could lead to residents accessing medications not prescribed to them, potentially causing harm. The facility's policy, revised in February 2016, clearly stated that all compartments containing medications must be locked when not in use, and that carts should not be left unattended if open or accessible to others.
Failure to Ensure Timely Medical Consultation and Wound Care
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there was a change in the resident's physical, mental, or psychosocial status. Specifically, the facility did not ensure that the MD and/or the Wound Care Doctor were consulted for direction on wound care orders for a resident upon readmission with two small open wounds on the right and left buttock. Additionally, the facility did not consult the MD and/or the Wound Care Doctor when a new wound developed on the resident's coccyx, leading to a significant delay in appropriate wound care and treatment. The resident was not seen by the Wound Care Doctor until several days later and was eventually sent to the hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. The resident, who had severe cognitive impairment and was at risk of developing pressure ulcers, returned to the facility from the hospital with two small open wounds. Despite the family requesting the use of a specific cream, the facility staff did not consult the MD or Wound Care Doctor for appropriate wound care orders. The Wound Care Nurse and other staff members failed to follow up with the necessary medical consultations and did not document or communicate the worsening condition of the resident's wounds in a timely manner. This lack of communication and failure to obtain proper treatment orders led to the deterioration of the resident's wounds. Interviews with various staff members, including the DON, ADON, and Wound Care Nurse, revealed that there was a lack of coordination and communication regarding the resident's wound care. The staff did not follow the facility's policy for consulting with the MD or Wound Care Doctor when changes in skin condition were noted. The resident's family was also not adequately informed about the worsening condition of the wounds. The facility's failure to ensure timely medical consultation and appropriate wound care placed the resident at risk of increased pain, infections, and serious harm.
Failure to Ensure Timely Wound Care Consultation
Penalty
Summary
The facility failed to ensure that residents received care consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. Specifically, the facility did not consult the MD or Wound Care Doctor for direction on wound care orders for a resident upon readmission with two small open wounds on the right and left buttock. Additionally, when a new wound developed on the resident's coccyx, the facility again failed to consult the MD or Wound Care Doctor in a timely manner. The resident was not seen by the Wound Care Doctor until 11 days later and was subsequently sent to the hospital with an unstageable wound on her sacrum, resulting in surgery to debride the wound. The resident, who had severe cognitive impairment and was always incontinent of bowel and bladder, was at risk of developing pressure ulcers. Upon readmission, the resident had two small open wounds on her buttocks, which were treated with a cream brought in by the family. The facility did not consult the MD or Wound Care Doctor about these wounds, attributing them to moisture and only warranting barrier cream. Despite the wounds not improving, the facility delayed obtaining consent for the Wound Care Doctor to see the resident, and the Wound Care Doctor was not consulted until the wounds had significantly deteriorated. Interviews with staff revealed that there was a lack of communication and proper documentation regarding the resident's wound care. The Wound Care Nurse and other staff members did not follow the facility's policy to consult the MD or Wound Care Doctor when changes in skin condition were noted. This failure to follow protocol and obtain timely treatment orders led to the resident's wounds worsening, ultimately requiring surgical intervention.
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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