Wedgewood Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 6621 Dan Danciger Rd, Fort Worth, Texas 76133
- CMS Provider Number
- 455572
- Inspections on file
- 50
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Wedgewood Nursing Home during CMS and state inspections, most recent first.
A facility failed to keep bedside call lights within reach for three residents who were observed in bed with the call light hanging down from the wall and out of reach. The residents had significant cognitive and functional impairments, including dementia, hemiplegia, legal blindness, and dependence for ADLs. Staff interviews confirmed that all employees were responsible for ensuring call lights were accessible, and the facility policy required call lights to be placed near the resident and never on the floor or bedside stand.
Failure to Provide Routine Fingernail Care: Multiple residents who were dependent on staff for ADLs were observed with long, dirty fingernails that had not been trimmed or cleaned despite care plans directing routine nail care. Residents with stroke, dementia, CVA, paraplegia, and cognitive impairment were found with nails extending beyond the fingertips, and several stated they wanted their nails cleaned and trimmed. Staff interviews confirmed that CNAs and nurses were responsible for nail care as part of personal hygiene.
Uncovered Food Items in Kitchen Storage: Food storage practices were not followed in the kitchen when tortillas were found open and exposed to air in dry storage and a box of lettuce was found open in the walk-in refrigerator. The Dietary Manager stated that all food items were expected to be covered at all times, and another staff member stated that uncovered food could lead to cross-contamination and illness.
Dignity During Meal Assistance: A resident with CVA, muscle weakness, and severe cognitive impairment was observed in bed while a CNA stood and assisted with feeding instead of sitting beside him. The CNA stated she should have sat while helping with the meal because standing could make a resident uncomfortable and lead to loss of dignity; the DON also stated staff should be seated when assisting residents with meals to maintain dignity.
A facility failed to ensure a resident's Temazepam blister pack on a nurses' cart was properly handled when 2 blister seals were broken and one was taped over with pills still inside. An LPN stated the shift count was correct but the blister packs were not checked, and the DON stated broken blister packs should not be kept with medication inside and that taping over them was unacceptable.
Improper hand hygiene and glove use occurred during incontinent care for a resident with an indwelling catheter and severe cognitive impairment. Two CNAs performed care, but one CNA sanitized gloved hands instead of changing gloves with hand hygiene while moving between contaminated and clean tasks, and the DON confirmed staff were expected to change gloves and not sanitize gloved hands. The facility policy stated gloves do not replace hand washing and hands should be washed after removing gloves.
A resident with COPD, respiratory failure, and severe cognitive impairment was sent to the ER after a fall and injury, and the facility treated the event as an AMA discharge when the family called 911 and the resident went to the hospital by ambulance. Facility notes stated the resident would not be accepted back, while the hospital record documented that the facility said the resident left AMA and would not return. The record also showed no documentation that the physician or designee contacted the resident or family and no Ombudsman involvement, despite the facility policy addressing AMA discharge and return procedures.
During a lunch meal, pureed rice pilaf was served with chunks and not at the required pudding-like consistency for residents on pureed diets. The DM did not verify the texture of the pureed food, and the staff member responsible acknowledged the rice was not smooth but served it anyway, contrary to facility policy.
A resident with multiple complex medical conditions experienced a change in condition resulting in hypoglycemia and hospital transfer. The facility failed to document the times for blood glucose monitoring, medication administration, and contacts with the NP and EMS. Staff interviews confirmed the importance of timely and complete documentation, and facility policy required such entries to be objective, chronological, and include all relevant details.
A facility failed to ensure proper treatment for a resident receiving enteral feeding, leading to a deficiency. A nurse used a de-clogger tool on a g-tube without physician orders, and the facility did not follow the prescribed water flush schedule, risking g-tube clogging. The resident had multiple medical conditions, requiring careful management of his feeding tube.
A facility with over 120 beds failed to employ a full-time social worker since late September 2024, as confirmed by resident interviews and record reviews. The absence of a social worker was acknowledged by the new Administrator, who stated that other staff members were addressing social service needs in the interim. The facility did not have a policy for social services.
The facility failed to provide adequate privacy curtains for several residents, leading to a lack of visual privacy during personal care. Observations showed that a resident had a curtain hanging by only four hangers, while another had no curtain at the foot of the bed. Staff interviews revealed a lack of awareness and responsibility for ensuring curtains were in place, and the facility lacked a specific policy on resident privacy.
A resident with severe cognitive impairment and physical limitations did not receive necessary nail care, resulting in untrimmed, jagged nails with a black substance underneath. Despite the resident's care plan indicating a need for extensive assistance with personal hygiene, observations showed her nails remained untrimmed over consecutive days. Staff interviews revealed that CNAs were responsible for nail care unless the resident had diabetes, but the facility's nail care policy was not followed.
A resident with a right hand contracture did not receive appropriate treatment as the facility failed to ensure the use of a splint or palm guard. The resident, with a history of aphasia and hemiplegia, was observed without a contracture management device for several days. Staff interviews revealed a lack of awareness and documentation regarding the use of the splint, and there was no physician's order in place, contrary to facility policy.
A facility failed to ensure physician orders for a resident's tracheostomy care, including suction tubing and an emergency trach kit. The resident, with a history of cerebral artery issues and respiratory failure, was admitted with a tracheostomy, but necessary orders were missing. Nursing staff continued care without orders, potentially leading to inadequate care. Facility policies requiring verification of physician orders were not followed.
The facility failed to prepare pureed mashed potatoes to the required pudding consistency for residents on pureed diets. The Dietary Manager used a whisk instead of a blender, resulting in lumpy potatoes, which could pose a choking risk. The facility's guidelines require a smooth consistency to prevent swallowing difficulties.
A facility failed to maintain an effective infection control program when a medical assistant did not sanitize a reusable blood pressure cuff between uses on two residents. Both residents required assistance with ADLs and had cognitive awareness. The medical assistant admitted to forgetting to sanitize the cuff, and the RNC showed a lack of understanding of the facility's policies, which required cleaning reusable items after use.
The facility failed to maintain a safe and sanitary environment in several resident rooms, with vent covers covered in dark debris resembling mold and a hanging ceiling rail posing injury risks. Staff interviews revealed a lack of communication and responsibility in addressing these issues, with the Maintenance Director ordering new vents only after being notified. The facility's Housekeeping Standards policy was not adhered to, placing residents at risk for infection and decreased quality of life.
A resident with multiple health conditions, including dementia and hemiplegia, was left in a soaked brief and bedding for about six hours without receiving necessary incontinence care. Despite the facility's policy requiring regular checks, the CNA responsible did not perform timely rounds, leaving the resident at risk for skin breakdown and infection. The facility's policy lacked specific guidelines on the frequency of incontinence checks.
A medication cart was found unlocked and unattended in a facility, with two residents nearby, one of whom was cognitively intact and on psychotropic medications. The ADON left the cart unsecured due to distraction, and the facility lacked a specific policy for medication cart security, as confirmed by the DON.
A facility failed to update a resident's care plan quarterly, as required. The resident, who was cognitively intact and had a history of stroke, cataracts, depression, and anxiety, had a care plan that had not been revised for several months. Interviews revealed that the DON was unfamiliar with the care plan update process, and the Administrator was unaware of the risks of not updating care plans.
Call Lights Left Out of Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that bedside call lights were adequately equipped and within reach for 3 of 5 residents reviewed for the resident call system. During observation on 04/21/2026, Resident #43 was lying in bed with the call light hanging down from the wall and away from him; he stated he could not reach it. Resident #43 had an admission date of 12/06/2014 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, cognitive communication deficit, and vascular dementia, with a BIMS score of 03 and a need for moderate assistance with showering and toileting hygiene. Resident #79 was also observed lying in bed with the call light hanging down from the wall and out of reach, and he stated he could not reach it. His record reflected an admission date of 11/01/2024, diagnoses including depression and cognitive communication deficit, a BIMS score of 00, and dependence on staff for toileting hygiene and showering. His care plan identified ADL self-care performance deficits, risk for not having needs met in a timely manner, functional limitations in range of motion, and hemiplegia/hemiparesis secondary to stroke, with ADL assistance required. Resident #92 was observed lying in bed with the call light hanging down from the wall and away from her, and she stated she could not reach it. Her record reflected an admission date of 02/25/2022, diagnoses including unspecified dementia and legal blindness, a BIMS score of 03, and dependence on facility staff for toileting hygiene and showering. Her care plan identified legal blindness, a high fall risk, and an ADL self-care performance deficit. Interviews with the charge nurse, CNA, and DON confirmed that staff were responsible for ensuring call lights remained within reach, and the facility policy stated call lights should be placed near the resident and never on the floor or bedside stand.
Failure to Provide Routine Fingernail Care
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for 7 residents who were unable to carry out those activities independently. During observation, interview, and record review, residents were found with fingernails that were long, dirty, and in need of trimming and cleaning, despite care plans that included nail care as part of routine personal hygiene support. Resident #1 had a history of stroke, arthritis, paraplegia, and a contracture of the right hand, and his BIMS score indicated intact cognition. His care plan directed staff to check nail length and trim and clean nails on bath day. On observation, his fingernails on both hands were long and dirty, and he stated staff had not offered nail care for the last few weeks and that he was unable to trim them himself because of his contracture. CNA A also observed that his fingernails were long and dirty. Resident #9 had a CVA, muscle weakness, severe cognitive impairment, and was dependent on staff for personal hygiene. His care plan directed staff to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. On observation, his fingernails were long with discoloration and dark residue under the nails, and he stated he wanted them trimmed and cleaned. RN D later observed the nails and stated they needed to be trimmed and cleaned. Resident #22 had dementia and cognitive communication deficit and needed moderate assistance with personal hygiene. His care plan directed staff to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. On observation, he had long, dirty fingernails with dark residue under several nails and stated he liked them trimmed short and cleaned. Resident #48, Resident #57, Resident #79, and Resident #87 were also observed with fingernails extending beyond the fingertips, and some had dirt or dark residue under the nails. Each of these residents stated they wanted their fingernails trimmed and/or cleaned, and their records reflected ADL self-care deficits with staff responsibility for personal hygiene and nail care.
Uncovered Food Items in Kitchen Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards in its only kitchen observed for food service safety. During observation of the dry storage area on 04/21/2026 at 10:18 AM, about 3/4 of a packet of tortillas was found left open and exposed to air in a cardboard box. During observation of the walk-in refrigerator on 04/21/2026 at 10:22 AM, a cardboard box containing about 5-6 heads of lettuce was found open to cold air. During interview on 04/22/2026, the Dietary Manager stated that all food items in the kitchen were expected to be covered at all times and that cooks, dietary aides, and she herself were responsible for ensuring proper coverage. She stated that not covering food items could lead to cross-contamination and decreased food quality, and that she provided frequent in-services on appropriate food storage practices. Another staff member stated that everyone working in the kitchen was responsible for ensuring food items were properly covered at all times and not exposed to air, and that uncovered food could result in cross-contamination and residents becoming sick. Facility policy and the FDA Food Code were reviewed and reflected that dry goods and refrigerated foods were to be stored properly in covered containers to prevent cross-contamination.
Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to care for the resident in a manner that promotes maintenance or enhancement of quality of life when the resident was assisted with eating while the CNA stood instead of sitting. Resident #9 was a male admitted with diagnoses including CVA and muscle weakness, and his quarterly MDS dated 03/11/26 reflected a BIMS score of 00/15 indicating severe cognitive impairment. His functional abilities for eating were listed as setup or clean-up assistance, and his care plan identified eating interventions as setup. During an observation on 04/22/26 at 08:54 AM, Resident #9 was in bed with the head of the bed elevated while CNA I stood and assisted him with his meal. The resident was unable to state how he felt about staff standing during the meal. During interview, CNA I stated she was supposed to sit next to the resident while assisting with the meal and said she should have gotten a chair and sat because standing could make a resident uncomfortable and lead to loss of dignity. The DON stated that all staff were responsible for maintaining resident dignity and that staff should be seated when assisting with meals to prevent residents from being uncomfortable. The facility policy on Resident Rights stated that residents have the right to a dignified existence, self-determination, and communication.
Broken blister pack medication left on nurses' cart
Penalty
Summary
The facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, including appropriate accessory and cautionary instructions and expiration dates when applicable. During observation of the 100/200 Hall nurses' cart, LVN F was found with Resident #29's Temazepam 15 mg capsule blister pack containing 2 broken blister seals with pills still inside the broken blisters, and one of the broken blisters had tape over it. LVN F stated the medication count had been completed at shift change and was correct, but she had not checked the blister packs during the count and did not know when the seals were broken or who damaged them. She stated it was not acceptable to tape over the broken seal and that the risk would be potential for drug diversion. The DON stated that if a blister pack medication seal was broken, the pill should be discarded and that it was not acceptable to keep a pill in an opened blister pack or to tape over the broken blister with medication inside. The DON also stated the risk would be potential for drug diversion and infection control issues. The facility policy titled Storage of Medications stated that medication carts are routinely inspected for discontinued, outdated, defected, or deteriorated medications with worn, illegible, or missing labels, and that these medications are removed and destroyed in accordance with facility policy.
Improper Hand Hygiene and Glove Use During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after staff failed to maintain proper infection control during incontinent care for a resident with an indwelling urinary catheter and severe cognitive impairment. The resident’s record reflected a quarterly MDS assessment with a BIMS score of 00/15, bladder continence with an indwelling catheter, and bowel continence frequently incontinent. The care plan identified the resident as at risk for urinary tract infections and catheter-related trauma and complications, with catheter care interventions and monitoring for signs and symptoms of infection. During observation, two CNAs entered the room, performed hand hygiene, donned gowns and gloves, and began incontinent care. CNA E cleaned the resident’s front area and catheter tubing, then sanitized her gloved hands while continuing care. After turning the resident to the side, CNA E again sanitized her gloved hands before cleaning the buttocks area and handling the brief, and CNA H later changed gloves with hand hygiene. In interview, CNA E stated she was supposed to change gloves with hand hygiene after cleaning the resident and was not supposed to sanitize gloved hands. The DON stated staff were expected to change gloves with hand hygiene and not sanitize gloved hands, and the facility policy stated gloves do not replace hand washing and hands should be washed after removing gloves.
Failure to Follow Return-to-Facility Policy After Hospital Transfer
Penalty
Summary
The facility failed to establish and follow its written policy for permitting a resident to return to the facility after hospitalization. Resident #38 was a female admitted with diagnoses including hypertension, asthma, COPD, and respiratory failure, and her discharge MDS reflected a BIMS score of 03/15, indicating severe cognitive impairment. Her care plan documented ADL self-care deficits related to chronic COPD and physical debility, fall risk, and hospice/terminal prognosis needs. On 04/21/26, after a fall and injury, the resident’s family was upset about the injuries and called 911. The resident was transported by ambulance to the hospital ER. Facility documentation stated the resident refused to sign an AMA form, took her personal belongings, and stated she would not be back. The DON notified the physician by telehealth and documented that the resident was in no distress before discharge. The facility later documented that the resident left AMA and would not be accepted back. Record review showed no documentation that a facility physician or designee contacted the resident or family after the event, and no documentation that the Ombudsman was contacted to help the resident find placement or assist with discharge. The hospital record documented that hospital staff called the facility and were told the resident left AMA and would not be accepted back. The facility’s own policy stated that residents leaving AMA are to be allowed to discharge at their own risk, with physician and DON notification, documentation of the circumstances, and completion of the AMA process. During interviews, the Administrator and DON stated the family taking the resident to the hospital was treated as a discharge and that the resident would need to go through readmission to return.
Failure to Prepare Pureed Food to Required Consistency
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual resident needs during a lunch meal. Specifically, pureed rice pilaf was not prepared to a pudding-like consistency as required for residents on pureed diets. Observation of a sample tray revealed that the pureed rice contained chunks of rice grains and was not fully pureed. The dietary manager (DM) acknowledged that the rice should have been smoother and easier to swallow, but did not check the texture of the pureed food items, citing that she had just started working at the facility and assumed the staff member responsible for preparing the pureed foods was knowledgeable about the requirements. The staff member who prepared the pureed foods confirmed that she made the pureed rice and believed it became chunky due to the addition of thickener. She admitted that the rice was not pudding-like or smooth but served it regardless. Review of the facility's policy indicated that meals should be provided according to physician orders and the facility diet manual, but this was not followed for the pureed rice during the observed meal.
Incomplete Clinical Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who experienced a significant change in condition. On the date in question, the resident, a male with multiple complex diagnoses including Type 1 Diabetes, End Stage Renal Disease, and Congestive Heart Failure, was transferred to the hospital after experiencing hypoglycemia. Documentation in the clinical record was incomplete, as the times for five blood glucose monitoring tests, three medication administrations, and contacts with the nurse practitioner and emergency medical services were not recorded. Interviews with facility staff confirmed that it is required practice to document the date, time, drug, and dose when administering medications, and to record the timing of significant events in the medical record. Staff acknowledged that failure to document these details could result in confusion for subsequent shifts and potentially lead to medication errors. The nurse responsible for the resident's care on the day of the incident admitted to usually documenting at the end of the shift and was unable to explain the omission of documentation for that day. Review of the facility's policy on clinical documentation emphasized the importance of objective, chronological, and complete entries, including the time of care and services provided. The policy also outlined procedures for late entries and corrections, underscoring the expectation that all significant events and care provided should be documented promptly and accurately. The lack of complete documentation in this case was inconsistent with both facility policy and accepted professional standards.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident receiving nutrition via enteral feeding received appropriate treatment and services to prevent complications. Specifically, a nurse used a de-clogger tool to unclog a resident's g-tube without obtaining prior physician orders, despite the facility not training nurses on the use of such tools. The facility had de-clogger tools on-site, although they were not an approved method for de-clogging g-tubes, and the nurse did not follow the protocol of notifying the physician before using the tool. Additionally, the facility did not adhere to the physician's orders regarding the flushing of the resident's enteral feeding tube. The orders specified that the tube should be flushed with 100 ml of water every 2 hours, but observations revealed that the water flush rate was set at 200 ml every 4 hours. This discrepancy was identified by a nurse during her shift, who then adjusted the feeding pump to the correct settings. The failure to follow the physician's orders posed a risk of the g-tube clogging, which could lead to serious complications for the resident. The resident involved was an elderly male with multiple medical conditions, including cerebral artery issues, aphasia, tracheostomy status, gastrostomy status, dysphasia, respiratory failure, and renal failure. The resident was unable to answer questions during observations, and his care plan indicated a need for careful management of his feeding tube to prevent aspirations, weight loss, and dehydration. The facility's failure to follow proper procedures and physician orders for enteral feeding placed the resident at risk for serious harm.
Facility Lacks Full-Time Social Worker for Over 60 Days
Penalty
Summary
The facility, which is licensed for more than 120 beds, failed to employ a qualified social worker on a full-time basis since September 26, 2024. This deficiency was identified through interviews and record reviews, revealing that the facility had not had a full-time social worker since the previous one was terminated on September 25, 2024. The absence of a social worker was confirmed by a confidential resident group interview, where all ten residents in attendance stated that the facility had been without a social worker for months. The residents were informed that the facility was actively searching for a new social worker. Further investigation showed that the facility's HR department confirmed the lack of a social worker since the end of September and mentioned that a new hire had been made, but the individual had not yet started. The newly employed Administrator, who began on January 13, 2025, confirmed that the facility had been without a social worker for approximately 60 days. During this period, the Director of Nursing (DON), Medical Records, MDS Coordinators, and Assistant Directors of Nursing (ADONs) were addressing residents' social service needs. However, the Administrator acknowledged the necessity of a social worker to advocate for residents' rights, participate in care planning, and ensure psychosocial needs were met. The facility did not have a policy for social services in place.
Failure to Ensure Resident Privacy Due to Inadequate Curtains
Penalty
Summary
The facility failed to ensure full visual privacy for four residents due to inadequate privacy curtains in their rooms. Observations and interviews revealed that Resident #3 had a privacy curtain hanging by only four hangers, leaving her exposed during personal care. She expressed discomfort with the lack of privacy, especially during incontinent care. Resident #47 had no privacy curtain at the foot of his bed and had requested either a curtain or a room change for more privacy, but his request had not been addressed. Resident #61, who currently had no roommate, noted discomfort when he previously shared the room without a privacy curtain between the beds. Resident #46 also lacked a privacy curtain at the foot of the bed, and there was no track for hanging one. He had been in this situation since moving into the room. Interviews with staff, including the ADON, CNA, RN, and supervisors of housekeeping and maintenance, revealed a lack of awareness and responsibility for ensuring privacy curtains were in place and functional. The housekeeping staff was responsible for changing and cleaning the curtains, while maintenance was tasked with repairs, but there was no surplus of curtains to replace those being washed. The facility did not have a specific policy addressing resident privacy or privacy curtains, only a general Resident Rights policy stating the right to a clean, comfortable, home-like environment. The lack of a clear policy and communication among staff contributed to the deficiency, as evidenced by the unaddressed issues with privacy curtains in multiple residents' rooms.
Failure to Provide Adequate Nail Care for Resident
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living to a resident with severe cognitive impairment and physical limitations. The resident, an elderly female with diagnoses including myopathy, reflux, unsteadiness on feet, and failure to thrive, required extensive assistance for personal hygiene as indicated in her care plan. Despite this, observations revealed that her fingernails were uneven, jagged, and had a black substance underneath, which the resident expressed dissatisfaction with, stating that her nails often got caught in her bedding. Interviews with facility staff indicated that nail care was the responsibility of CNAs unless the resident had diabetes, in which case a nurse would perform the task. However, despite the resident's need for assistance, her fingernails remained untrimmed over consecutive days. The facility's nail care policy outlined specific procedures for nail care, but these were not followed, leading to the resident's unkempt nails and potential risk for infections or injuries.
Failure to Provide Contracture Management for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a right hand contracture, which is a permanent tightening of the muscles. The resident, who is an elderly male with a history of aphasia, hemiplegia, and memory problems, was observed without a contracture management device in place over several days. Interviews with staff revealed that the resident had a splint for his hand contracture, but it was not applied because it was likely in the laundry. Staff members, including a CNA, LVN, and the Occupational Therapist, were unaware of the resident's current use of the splint, and there was no physician's order for the splint or palm guard. The Occupational Therapist noted that the palm guard had not been located for about two weeks, and there was no clear documentation or order for its use. The facility's policy on splinting requires a physician's order and an Occupational Therapist evaluation, which were not in place for this resident. The absence of the splint or palm guard could lead to further tightening of the contracture, skin breakdown, and pain from stiffness, as noted by the ADON. The lack of consistent application of the contracture management device and the absence of a formal order contributed to the deficiency in care for the resident.
Failure to Ensure Physician Orders for Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as there were no physician orders for tracheostomy care, suction tubing, or an emergency trach kit. This deficiency was identified for a resident who was admitted with a tracheostomy and had a history of cerebral artery issues, aphasia, respiratory failure, and renal failure. The resident's care plan indicated the need for tracheostomy care, but the necessary physician orders were missing, which could lead to inadequate care. Observations revealed that the resident had a tracheostomy and feeding tube, and an emergency kit was present at the bedside. However, interviews with nursing staff indicated that the admitting nurse failed to input the necessary orders into the system, and the orders might have been deleted after the resident's hospital visit. The nurse assigned to the resident was unaware of the missing orders and continued to provide care without them, which could give the impression that care was not being provided. The facility's policies required verification of physician orders for tracheostomy care, but these were not followed. The ADON and RNC were unaware of the missing orders and emphasized the importance of obtaining and entering physician orders into the system. The lack of physician orders could potentially lead to the resident not receiving the necessary tracheostomy care, as outlined in the facility's policies.
Failure to Prepare Pureed Food Consistently
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for residents requiring pureed diets. During a lunch meal, the facility did not prepare and serve pureed mashed potatoes with the required pudding consistency. Instead, the mashed potatoes contained chunks and were not fully mashed, which was observed during a test tray review. The Dietary Manager used a hand whisk instead of a blender to puree the mashed potatoes and did not verify the consistency before serving. The Dietary Manager acknowledged that the mashed potatoes were not smooth and contained lumps, which could pose a choking risk to residents. The facility's Pureed Recipe Book General Guidelines policy specifies that pureed foods should have a moist mashed potato consistency to prevent swallowing difficulties or aspiration. The Dietary Manager admitted to normally overseeing staff in preparing pureed meals but was directly involved in preparing the mashed potatoes on this occasion.
Inadequate Sanitization of Medical Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a medical assistant (MA D) who did not sanitize a reusable blood pressure cuff between uses on two residents. Resident #5, a male with kidney disease, diabetes, high blood pressure, and heart failure, required assistance with all activities of daily living (ADLs) and had a BIMS score indicating he was cognitively intact. Resident #60, a male with complete paralysis and mild cognitive impairment, also required total assistance with ADLs and was cognitively intact. Observations revealed that MA D used the same blood pressure cuff on both residents without sanitizing it between uses, which could expose residents to infections. Interviews with MA D and the Registered Nurse Coordinator (RNC) highlighted a lack of awareness and understanding of the facility's infection control policies. MA D admitted to forgetting to use sanitizing cloths, despite having them available, and acknowledged the risk of spreading infections. The RNC incorrectly stated that reusable medical equipment only needed to be sanitized if visibly soiled and was unable to articulate the risks of not sanitizing equipment between uses. The facility's policy required cleaning and storing reusable items after use, which was not followed in this instance.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in four of the five rooms reviewed for environmental conditions. Observations revealed that the vent covers in Rooms 221, 225, 229, and 231 were covered with dark debris, resembling mold, dust, and dirt. The vents appeared to have thick black dust and debris both inside and outside. Additionally, a silver ceiling rail was found hanging from the ceiling in one of the rooms, posing a risk of injury to residents and staff. Interviews with staff members, including a housekeeper, a CNA, an LVN, and the Maintenance Director, indicated a lack of communication and responsibility in addressing the environmental issues. The housekeeper was aware of the dirty vents but had not reported them to the Maintenance Director, assuming he would have checked all vents. The CNA acknowledged the potential health risks posed by the dirty vents but had not reported them either. The LVN was informed of the issues but had not yet observed the vents herself. The Maintenance Director stated that he was responsible for cleaning the vents and had ordered new ones after being notified of the problem. The facility's Administrator acknowledged the deficiencies and stated that staff conducting Angel Rounds should have reported the issues. The facility's Housekeeping Standards policy emphasized the importance of maintaining a clean and sanitary environment to prevent the spread of disease and infection. However, the lack of adherence to these standards resulted in the identified deficiencies, placing residents at risk for infection and decreased quality of life.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, a female with a history of stroke, hypertension, peripheral artery disease, hemiplegia, dementia, seizure disorder, and anxiety disorder, was found to be frequently incontinent of bowel and bladder. Despite requiring partial/moderate assistance with toileting, showering, bathing, and personal hygiene, the resident was left in a soaked brief and bedding for approximately six hours without being changed. Observations and interviews revealed that the resident had been in bed since the start of the 6:00 AM-2:00 PM shift and had not received incontinence care until 11:50 AM. The resident expressed discomfort and dissatisfaction with being left wet. CNA A, responsible for the resident's care during this shift, admitted to not checking on the resident for incontinence care since around 10:00 AM, as the resident was sleeping. The CNA acknowledged the importance of ensuring residents are clean and dry to prevent skin damage and irritation. The facility's Director of Nursing (DON) confirmed that CNAs are responsible for conducting rounds every two hours to ensure residents are clean and dry, and that nurses should also check on residents. The facility's incontinence care policy outlined procedures for cleaning after an incontinence episode but did not specify the frequency of checks. The failure to provide timely incontinence care placed the resident at risk for skin breakdown, infection, and pressure sores.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by State and Federal laws. During an observation on the 100 halls, a medication cart was found unlocked and unattended. This occurred on 04/30/24 at 9:20 AM, with residents in close proximity to the unsecured cart. Resident #3 was sitting next to the cart, and Resident #1 was observed moving independently in his wheelchair near the cart multiple times. The medication cart remained unsupervised until 9:34 AM when another employee locked it, indicating that ADON A was responsible for the cart. Resident #1, a male with a history of cerebral infarction, depression, and anxiety, was cognitively intact with a BIMS score of 15. He required supervision for activities of daily living and was on psychotropic medications. Despite his cognitive status, he was observed near the unlocked medication cart, which posed a risk given his behavioral history of physical and verbal aggression. Resident #2, a female with severe cognitive impairment and dementia, was also near the cart, asleep in her wheelchair, and moving closer to it intermittently. Interviews with staff revealed that ADON A left the cart unlocked due to being distracted by another task. Both the DON and the Administrator acknowledged the expectation that medication carts should be locked when unattended to prevent unauthorized access. However, the facility lacked a specific medication cart security policy, as confirmed by the DON. This oversight in securing medication carts could potentially lead to residents accessing medications, posing risks of overdosing or adverse reactions.
Failure to Update Resident Care Plans Quarterly
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. This deficiency was identified for one resident, a cognitively intact male with a history of cerebral infarction, cataracts, depression, and anxiety. The resident's care plan, dated several months prior, had not been updated as required, despite the resident's ongoing need for supervision with activities of daily living and the use of psychotropic medications for depression and anxiety. Interviews with facility staff revealed a lack of familiarity and training regarding the care plan update process. The Director of Nursing (DON), who had been in the position for two weeks, acknowledged that the care plans should have been updated quarterly and was not aware of the facility's process for updating them. The facility's Administrator was aware of a backlog of care plans that had not been updated by previous nursing staff and had hired new nurse managers to address the issue. However, the Administrator was unaware of the risks associated with not updating care plans.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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